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NERVOUS  DISEASES: 


THEIR 


DEvSgetption  and  Treatment. 


A  Manual  for  Students  and  Practitioners  of  Meiiciue. 


BY 

ALLAI^  McLAl^E  HAMILTOIs^,  M.D., 

FKLI.OW  OF   THE   NEW   YOEK   ACADEMY   OF  MEDICINE;     ONE   OF   THE  ATTENDING   PHYSICIANS  AT   TH  l' 

HOSPITAL    FOE   EPILEPTICS  AND  PARALYTICS,  BLACKWELL'S  ISLAND,  NEW  YOPvK  CITY;     ONE  OF 

THE  CONSULTING  PHYSICIANS  AT  THE  HUDSON  KIVER  STATE  HOSPITAL  FOR  THE  INSANE, 

AND  MALf;  AND  FEMALE  INSANE  ASYLUMS  OF  NEW  YORK  CITY,  ETC.,  ETC.,  BTC. 


SECOXD  EDITION— REVISED  AND  ENLARGED. 
With  Seventy-two  Illustrations. 


PHILADELPHIA: 

HEISTEY   C.  LEA\S   SOI^  &  CO, 

1881. 


Entered  according  to  Act  of  Congress,  in  the  year  1881,  by 

HENRY    C.LEA'S     SON    &    CO, 

In  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved. 


fiRANT,    F.\IRKS   &    RODGEBS, 

KUclroti/pers  and  Printers, 
.52  &  .54  Nurth  Sixth  Street. 


TO   MY   FRIENDS 


FOEDYCE     BARKER,     M.  D., 


JOHN     T.     METCALFE,    M.  D 


MEREDITH   CLYMER,  M.D., 

THE   PIONEER 
IN  THE   FIELD   OF   MODEKN   NEUROLOGICAL  LITERATURE   IN   AMERICA. 


PREFACE   TO   THE   SECOND   EDITION. 


In  presenting  a  new  edition  of  my  l)ook  I  wish  to  express  to 
tlie  profession  my  hearty  appreciation  of  the  favorable  reception 
accorded  to  the  first,  which  has  been  ont  of  print  for  several  months, 
I  thank  my  impartial  reviewers,  and  take  pleasure  in  saying  that 
>\dierever  possible,  I  have  endeavored  to  adopt  their  suggestions, 
and  I  trust,  have  succeeded  in  remedying  tlwi  faults,  many  of  whicli 
are  unavoidable  in  a  first  edition. 

The  present  edition  is  enlarged  l)y  nearly  one  hundred  pages 
and  contains  many  new  illUvStrations,  in  fact  this  feature  of  the 
book  has  undergone  an  almost  entire  change.  The  enlargement  is 
a  matter  of  necessity,  owing  to  the  recent  advances  in  our  know- 
ledge of  neurological  medicine.  I  have  used  certain  portions  of  my 
essay  which  received  the  prize  of  the  American  Medical  Association, 
in  1879,  in  the  preparation  of  a  chapter  upon  diseases  of  the  lateral 
columns  of  the  spinal  cord.  Other  chapters  have  been  remodeled, 
and  I  hope  improved,  especially  in  regard  to  the  introduction  of 
matter  relative   to  localization   of  disease   in   the   brain  and   spinal 

(^ord. 

ALLAN   McLANE  HAMILTON, 

New  York,  43  East  33d  St. 
Nov.  1st,  1881. 


PEEFACE   TO   THE   FIRST   EDITION. 


It  has  been  my  object  to  produce  a  concise,  practical  book;  and 
should  the  satisfaction  be  ever  accorded  me  of  knowing  that  I  have 
made  the  subjects  of  Diagnosis  and  Treatment  of  Nervous  Diseases 
more  simple  to  my  readers  than  I  think  they  now  are,  I  shall  be 
amply  rewarded  for  the  task  I  have  undertaken. 

I  have  not  considered  Insanity,  because  I  believe  that  this  subject 
deserves  much  more  extended  notice  than  it  could  possibly  receive  in 
a  book  of  this  size  and  kind. 

I  have  deemed  it  advisable  to  include  a  short  article  upon  Cerebro- 
spinal Meningitis,  though,  by  many  authorities,  it  is  not  regarded, 
strictly  speaking,  as  a  nervous  disease.  I  think,  if  for  no  other 
reason,  its  interestiug  diagnostic  relations  entitle  it  to  consideration. 

In  conclusion,  I  wish  to  thank  Drs.  Loring,  Janeway,  Mason, 
Shakespeare,  my  resident  physicians,  Drs.  Meyer,  Naylor,  Eyan,  and 
Baldwin,  and  Mr.  F.  O.  C.  Darley,  for  valuable  assistance  in  the 
preparation  of  this  volume. 

ALLAN  McLANE  HAMILTON. 

New  York,  Mat  1st,  1878. 


CONTENTS 


INTRODUCTION. 

PAGE 

I.  Hints  ly  regard  to  Methods  of  Examination  and  Study — Examina- 
tion of  the  patient,  symptomatology,  etc. — Aiitopsical  and  microscopical 
examinations  ...........     17-21 

II.  Instruments  used  for  the  Diagnosis  and  Treatment  of  Xervous 
Diseases — The  Thermometer,  ^Esthesiometer,  Dynamometer,  Ophthalmo- 
scope, The  Percussion  hammer — Apparatus  for  the  Treatment  of  Ner- 
vous Diseases — Electrical,  Rubber  Muscles,  Hypodermic  Syringe,  Ether- 
Spray  Apparatus,  Spinal  and  Cranial  Ice-bags,  Cauteries,  etc.         .         .     22-37 

CHAPTER   1. 

diseases   of  the   cerebral  5IENINGES. 

Cerebral  Pachymeningitis — Acute,  chronic — Chronic  Pachymeningitis  with 
hematoma — Acute  Cerebral  Meningitis,  basal,  vertical — Rheumaiic  Menin- 
gitis— Meningitis  of  the  Aged — Acute  Granular  (Tubercular)  Meningitis^ 
Acute  granular  meningitis  of  the  convexity — Chronic  Cerebral  Meningitis  38-75  ' 

CHAP.TER   II. 

DISEASES   OF   THE  CEREBRXJil   AND   CEREBELLUM. 

Symptomatic  Cerebral  Hypercemia — Cerebral  Hemorrhage    .        .         .     76-126 

CHAPTER   III. 

DISEASES   OF   THE   CEREBRUM  AND   CEREBELLUM:"(C0NTINUEd). 

Symptomatic  Cerebral  Ancemia  (acute,  chronic,  infantile) — Stomachic  Vertigo 
— Auditory  Vertigo 127-144 

CHAPTER  IV. 

DISEASES   OF  THE   CEREBRUM  AND   CEREBELLUM    (CONTINUED). 

Occlusion  of   Intra-Cranial   Vessels — Thrombosis — Embolism — Throm- 
bosis of  the  Cerebral  Arteries — Thrombosis  of  Sinuses  and  Veins — Embol- 
ism of  the  Cerebral  VesselSf        ........     145-163 

xi 


XU  CONTENTS. 

CHAPTER   V. 

DISEASES   OF   THE   CEREBRUM   AND   CEREBELLUM    (CONTINUED), 

PAns 

Cerebral  Softening — Acute,  chronic — Asemasia  (aphasia) — Cerebral  Scle- 
rosis— Diffused  Cerebral  Sclerosis 163-204 

CHAPTER   VI. 

DISEASES   OF   THE   CEREBRUM   AND   CEREBELLUM    (CONCLUDED). 

Brain  Tumors — Cerebellar  Hemorrhage — Tumors  of  the  Cerebellum — Soften- 
ing and  Abscess  of  the  Cerebellum 205-23.'> 

CHAPTER   VII. 

DISEASES   OF   THE   SPINAL   MENINGES. 

Spinal  Meningitis  (acute  pachymeningitis) — Acute  and  Chronic  Spinal 
Meningitis — Spinal  Pachymeningitis — Spinal  Tumors — Spinal  Hemorrhage. 
meningeal,  central  .         ...         .         .         .         .         .         .     23(i-2ri4 

CHAPTER    VIII. 

DISEASES  OP  THE  SPINAL  CORD. 

Spinal  Hypercemia  Spinal  Congestion,  Subacute  Spinal  Hyperaemia — 
Spinal  Irritation        .         .        ' 255-264 

CHAPTER    IX. 

DISEASES   OF  THE   SPINAL   CORD    (CONTINUED). 

Inflammation  of  the  Spinal  Cord — Myelitis — acute,  chronic — Acute  Ascend- 
ing Paralysis — Antero-Spinal  Paralysis  of  Infants — Of  Adults    .     265-294 

CHAPTER    X. 

DISEASES   OF    THE   SPINAL   CORD   (CONTINUED). 

Progressive  Muscular  Atrophy — Partial  Facial  Atrophy — Pseudo-IIyper- 
trophic  Muscular  Paralysis 295-320 

CHAPTER    XI. 

DISEASES   OF   THE   SPINAL   CORD    (CONTINUED). 

Posterior  Spinal  Sclerosis  (Locomotor  Ataxia) — Sclerosis  of  the  columns  of 
GoU — Antero- Lateral  Amyotrophic  Sclerosis 321-346 

CHAPTER    XII. 

DISEASES   OF  THE  SPINAL   CORD    (CONCLUDED). 

Infantile  Spastic  Paralysis — Functional  Disease  of  the  Lateral  Columns — 
Hysterical  Spasmodic  Spinal  Paralysis — Primary  Degeneration  of  the 
Lateral  Columns — Tetanus 347-383 


PAOB 


CONTENTS. 
CHAPTER    XIII. 

BTTLBAH  DISEASES. 

Epilepsy — Bulbar  Paralysis 384-420 

CHAPTER    XIV. 

CEBEBBO-SPINAX  DISEASES. 

Cerebro- Spinal  Meningitis — Cerebro- Spinal  Sclerosis — Alcoholism — acute 
— chronic  —  Nicotinism  —  Hydrophobia  —  Hysteria  — Hystero-Epilepsy  — 
Catalepsy^ 421-482 

CHAPr,ER    XV. 

CEBEBBO-SPINAL  DISEASES    (CONCLUDED). 

Chorea — Paralysis  Agitans — Exophthalmic  Goitre       ....     483-510 
CHAPTER    XVI. 

DISEASES   OF  THE  PERIPHERAL  NERVES. 

Neuralgia,  facial,  cervico-occipital,  cervico-brachial,  intercostal,  or  pleuro- 
dynia— Sciatic — Crural,  visceral,  ovarian,  urethral,  renal,  etc.      .         .     511-53Y 

CHAPTER    XVII. 

DISEASES   OF   THE  PERIPHERAX,  NERVES   (CONTINUED). 

Neuritis — Ancesthesia — Tumors  of  Nerves 538-647 

CHAPTER    XVIII. 

DISEASES   OF  THE  PERIPHERAL  NERVES   (CONTINUED). 

Local  Paralysis  —  Facial  paralysis  —  Traumatic  paralysis  —  Diphtheritic 
paralysis ,         .         .     548-565 

CHAPTER    XIX. 

DISEASES   OF  THE  PERIPHERAL  NERVES   (CONCLUDED). 

Lead  Poisoning — Fxinctional  Spasm — Tetany — Functional  spasm  with  vol- 
untary movements — Reflex  spasm — Facial  spasm  without  pain — Torticollis 
— Professional  Cramp — Writer's  Cramp — Dancer's  Cramp — Telegrapher's 
Cramp,  etc.,  etc. —  (Esophagismus 566-587 


LIST  OF  ILLUSTRATIONS. 


FIG.  PAOK 

1.  Seguin's  Surface  Thekmometer 22 

2.  Gbay's  System  of  Head  Straps 23 

3.  Sibveking's  ^sthesiometer 26 

4.  Diagram  fob  making  Records 28 

5.  Mathieu's  Dynamometer 2!^> 

6.  The  Author's  Dynamometer 30 

7.  Loring's  Ophthalmoscope 31 

8.  Percussion  Hammer 33 

9.  Manner  of  Tssting  Tendon-reflex.     (Gowers) 34 

10.  The  Author's  Gas  Cautery 36 

11.  Osteoma  of  Dura  Mater.     {Lancereaux) 43 

12.  Tuberculous  Matter  about    Vessels.     {Cornil-  and  Eanvier) 66 

13.  Distended  Perivascular  Spacbs.     {Fothergill) 86 

14.  15.  Tracings  of  Patellar  Tendon-Reflex.     (Brissaud) 101 

16.  Cortical  Centres.     {Morel) - 105 

17.  Charcot's  Scheme  of  Cerebral  Motor  Tracts 107 

18.  Internal  Cerebral  Vascular  Supply.     {Charcot) 110 

19.  External  Cerebral  Vascular  Supply.     {Charcot) Ill 

20.  Miliary  Aneurisms 113 

21.  Multiple  Lesions  with  Tongue  Atrophy .  -    .    .  117 

22.  Instrument  for  Applying  Heat  and  Cold 126 

23.  Tissue  Changes  in  Softening 175 

24.  Handwriting  of  Agraphic  Patient.     {Boumemlle) 184 

25.  Handwriting  of  Patient  with  Cerebro-Spinal  Sclerosis  and  Agraphia  184 

26.  Plate  Showing  Third  Frontal  Convolution.    {Baieman)  .......  186 

27.  Choked  Disk.     {After  Leibreich) 208 

28.  Plate  Showing  Decussation  of  Optic   Nerve  Fibres.     {Charcot)    .    .    .  209 

29.  Tubercular  Deposit 212 

30.  Sarcoma  of  Brain 212 

31.  Gumma  op  Brain 213 

32.  PsAMMOMA  OF  Brain 213 

33.  Encephaloid  of  Brain 213 

34.  Glioma  of  Brain 213 

34a.  Cerebellar  Aneurisms.     {Bristowe) 229 

35.  Deformity  op  Hand  in  Cervical  Pachymeningitis.     {Charcot) 238 

36.  Scheme  of  Conductors  in  Cord  .    .  ^ 246 

XV 


Xvi  LIST   OF   ILLUSTRATIONS. 


via. 


PAOK 

37.  Diagram  Showing  Relation  of  Motor,  Sensory,  and  Reflex  Functions 

OF  Cord.     (Gowers) ^'^ 

38-41.    Muscular    Changes    in     Antero-Spinal     Paralysis    of     Infants. 

OQ.A 

(Duchenne) -°^ 

42.  Antero-Spinal  Paralysis.     (Seguin) .  • -87 

43.  Main  en  Griffe.     {Duchmne) 296 

44.  Perimeter  of  Chest  in  Progressive  Muscular  Atrophy.    (Duchenne)  .  300 

45.  Atrophy  of  Left  Shoulder "^^ 

46.  Partial  Facial  Atrophy 309 

47.  Pseudo-Hypeetrophic  Paralysis.    {Gowers} 314 

48.  Mechanics  of   Muscular   Action  in    Pseudo-Hyfertrophic   Paralysis. 

(Gowers) 316 

49.  Appearance  of   Muscular  Tissue  in  Pseudohypertrophic   Paralysis. 

(Charcot) 319 

50.  Appearance  of  Trophic  Changes  in  Locomotor  Ataxia.    (Charcot)  ...  332 

51.  Course  of  Posterior  Nerve-Root  Fibres.     (Clarke) 335 

52.  Sclerosis  of  Columns  of  Goll.     (Charcot) 341 

53.  Method  of  Provoking  Dorsal  Clonus.     (Gowers) 350 

54.  Contraction  of   Feet  in  an  Advanced  Case  of   Primary    Degenera- 

tion OF  THE  Lateral  Columns 357 

.%.  Syringo-Myelia  and  Hydro-Myelia.     (Leyden) 360 

56.  Scheme  of  Fibre  Connection  in   Lateral  Columns.     (Flcchsig)  ....    361 

57.  Sclerosis  of  Lateral  Columns 366 

58.  Map  of  Suffolk  Co.,   Long  Island,  Showing   Prevalence  of   Endemic 

TETANUS 376 

59.  Retraction  of  Head  in  Cerebro-Spinal  Meningitis.    (Levns  Smith)  .   .    422 

60.  The  Pathology  of  Hysteria 467 

61-64.  Attitudes  of  Hystero-Epileptic.     (Bourneville  and  Regnard)     .    .471-475 

65.  Exophthalmic  Goitre    ( Yeo) 505 

66.  Charts  Showing  Nervous  Areas.    (After  Henle)    .   .   . 532 

67.  The  Author's  Percuteur 535 

68.  Trophic  Changes  of  Skin  or  Hand  in  Neuritis 539 

69.  Sarcomatous  Neuroma.    (Foucault) 547 

70.  Wire  Hook  foe  Treating  Facial  Paralysis 553 

7L  Reflex  Spasm  from  Genital  Irritation 577 

72.  Instrument  Used  for  Treatment  of  Torticollis 580 


NERVOUS   DISEASES. 


INTRODUCTION. 

HINTS  IN  KEGAED  TO  METHODS  OF  EXAMINATION 
AND  STUDY. 

Ik  beginning  our  consideration  of  the  diseases  which  are  to  form  the 
subject  of  the  succeeding  pages,  it  is  well  to  start  with  systematic  rules 
for  investigation,  and  it  is  of  paramount  importance  that  we  should  pursue 
some  plan  which  will  enable  us  to  avoid  confusion,  and  assist  us  in  making 
an  accurate  diagnosis  by  exclusion.  I,  therefore,  propose  a  scheme  to  be 
used  in  the  examination  of  patients,  and  would  add  a  word  of  caution  in 
regard  to  the  error  many  of  us  make  in  too  readily  accepting  and  isolating 
nervous  symptoms  as  distinct,  which,  after  all,  may  be  expressions  of  some 
general  disorder.  It  too  often  happens  that  simple  digestive  disturbances, 
cholestersemia,  or  perhaps  ursemic  poisoning  give  rise  to  symptoms  that  are 
seized  upon  as  the  basis  of  a  distinct  nervous  disease,  and  the  error  is  not 
recognized  in  time  to  arrest  the  true  mischief. 

We  are  to  determine  the  existence  and  relation  of  disorders  of  motility 
and  sensation,  as  well  as  mental  symptoms,  defects  of  speech,  sight,  or 
hearing,  together  with  the  causes  which  enter  into  their  production. 

EXAMINATION  OF  THE  PATIENT. 

Prelimixary  Examination. — Sex,  age,  temperament,  appearance, 
duration  of  present  disease,  existence  of  complicating  maladies,  previous 
history,  hereditary  predisposition,  habits. 

SYIMPTOINIATOLOGY. 

Motility,  degree  of,  location  of  loss  or  increase  (one  side  or  one-half 
of  body?),  groups  of  muscles  or  single  muscles,  face,  trunk,  or  extremities, 
lateral  or  bilateral,  symmetrical  or  unsymmetrical,  loss  or  exaggeration 
of  electro-muscular  contractility,  fibrillary  contractions,  muscular  power, 
associated  with  deformities  or  contractures ;  atrophy  or  hypertrophy,  gen- 
eral or  partial ;  spasms,  tonic  or  clonic,  attended  or  unattended  by  loss  of 
consciousness;  condition  of  reflex  excitability. 

Tremor. — Local  or  general,  increased  or  controlled  by  will,  "fine"  or 
"  coarse;"  time  of  day,  continuous  or  at  intervals;  subsidence  or  continu- 
ance during  sleep;  whether  evoked  by  jarring  limb,  or  by  tapping  tendons 
or  muscles;  increased  or  stopped  by  flexion  or  extension  of  foot;  accom- 
panied or  not  by  pain  ;  associated  or  not  with  rigidity  of  joints  when  limb 
is  flexed 

2  17 


18  INTRODUCTION. 

Incoordination  of  upper  or  lower  extremities,  variety  of  action  in  which 
it  occurs;  gait;  aggravation  by  closure  of  eyes;  loss  of  muscular  sense; 
loss  of  locating  power. 

Sensation. — General  or  partial  anaesthesia ;  dyssesthesia  or  hyperaes- 
thesia ;  susceptibility  to  painful  impressions ;  temperature ;  tactile  sensibili- 
ty ;  sensibility  to  pressure;  pain,  localized  or  general;  character  of  pain, 
neuralgic,  terebrating,  dull,  or  paroxysmal ;  time  when  aggravated ;  its 
associations  ;  time  of  transmission  of  sensation  ;  appreciation  of  form. 

Disorders  of  Organs  .of  Special  Sense. 

JEyes. — Nystagmus,  strabismus,  conjugate  deviation  (see  article  Cere- 
bral Hemorrhage),  retinal  changes,  corneal  changes,  pupillary  changes, 
ptosis,  diplopia,  amblyopia,  amaurosis.     The  existence  of  color  blindness. 

Ear. — Deafness,  subjective  noises,  discharge. 

Speech. — Aphasia,  slow  speech,  clumsy  speech,  ataxic  speech,  loss  of 
speech  (mutism).     Visual  and  auditory  relations. 

Vertigo. — Variety ;  concomitant  phenomena. 

Psychical  Disorders — Illusion,  hallucination,  delirium,  mania,  me- 
lancholia, delusions,  and  their  character,  loss  of  memory,  loss  of  con- 
sciousness, imbecility,  idiocy,  excitability,  dementia. 

Miscellaneous. — Character  of  cutaneous  surface,  changes  in  tempera- 
ture of  general  surface  or  localized  spots,  cranial  temperature,  variation 
in  salivary  secretions,  changes  in  pigmentation  and  appearance  of  hair, 
perspiration,  etc. 

Exciting  Causes  ;  Diagnosis  ;  Treatment. 

This  list,  though  imperfect,  will,  I  think,  enable  the  observer  to  pursue 
a  systematic  course  in  examining  his  patient.  He  should,  at  the  same 
time,  take  careful  notes  for  future  reference,  so  that  variations  in  the 
symptoms  and  changes  of  treatment  may  be  remembered. 

Before  leaving  the  subject  of  examination,  I  wish  to  refer  to  the  value 
of  post-mortem  examination  and  microscopical  investigation  of  the  morbid 
anatomical  changes.  These  subjects  belong  more  properly  to  special  works 
upon  pathology  and  microscopy,  but  it  may  not  be  amiss  to  add  a  few  hints 
to  those  already  given  in  regard  to  certain  important  steps  to  be  taken.  In 
removing  the  ealvarium  the  thickness  of  the  cranial  bones  should  be  noted, 
as  well  as  the  condition  of  the  diploe ;  but  extreme  care  should  be  em 
;ployed,  in  sawing  through  the  bone,  not  to  wound  the  meninges  and  brain- 
.substance  beneath;  for  the  saw-teeth  may  unexpectedly  tear  through, 
lacerating  and  injuring  these  parts,  so  that  they  may  be  almost  useless 
for  subsequent  examination.     After  the  skullcap  has  been  removed,  the 


POST-MORTEM   EXAMINATION.  19 

observer  should  be  on  the  lookout  for  Pacehonian  bodies,  and  ready  to  re- 
cognize any  adventitia  that  may  be  attached  to  the  dura  mater.  The  condi- 
tion of  the  longitudinal  sinus  and  veins  which  are  contained  in  the  dura  ma- 
ter should  be  examined  as  to  their  fulness,  etc. ;  the  thickness,  vascularity, 
color,  and  opacity  of  their  tissue  should  also  be  carefully  noted  and  then  an 
incision  may  be  made,  and  this  membrane  slit  up  with  a  pair  of  blunt- 
pointed  scissors,  or  it  may  be  cut  around  at  the  level  of  the  saw  cut. 
The  arachnoid  and  pia  mater  are  then  to  be  inspected :  the  existence  of 
effusion,  either  serous,  purulent,  or  bloody;  and  the  presence  of  granular 
deposit  or  vascular  changes  noted.  The  brain  should  be  lifted  back,  and 
the  cranial  nerves  carefully  cut  as  near  as  possible  to  their  points  of  exit 
from  the  skull,  the  optic  first,  and  then  the  carotid  arteries  and  posterior 
nerves  ;  next  the  tentorium,  and  finally  the  other  nerves,  vertebral  arte- 
ries, and  the  spinal  cord  as  low  down  as  possible,  taking  care  not  to  make 
pressure  by  insinuating  the  finger  into  the  foramen  magnum.  The  brain 
may  then  be  removed.^  If  it  is  desired  to  remove  the  cord,  the  skin  and 
muscular  tissue  of  the  back  should  be  divided  and  thrown  back,  and  the 
spinous  processes  and  laminse  exposed.  These  latter  should  be  sawn 
through  on  each  side  and  carefully  raised  by  the  blade  of  the  chisel^ 
When  the  brain  is  removed,  it  should  be  placed  with  the  base  downwards, 
and  the  appearance  of  the  convolutions  noted,  the  membranes  having 
been  removed.  Evidences  of  pressure  are  to  be  looked  for,  and  the  color  is 
to  be  noticed,  as  well  as  the  depth  of  the  sulci  and  superficial  evidences 
of  softening  or  sclerosis,  morbid  growths,  and  infiltration.  The  organ  may 
be  turned  over,  and  the  arteries  at  the  base  inspected  in  regard  to  the 
existence  of  anomalies,  aneurisms,  degeneration,  thrombosis,  or  embolism. 
The  fissure  of  Sylvius  may  be  next  examined,  and  the  middle  cerebral  artery 
traced  by  sections.  As  to  the  method  of  making  cuttings  of  the  brain, 
we  may,  perhaps,  find  resort  to  the  horizontal  section  of  Flechsig,  espe- 
cially when  the  patient  has  presented  before  death  symptoms  indicative 
of  degeneration  of  the  internal  capsule.  We  are  enabled  to  carefully 
compare  by  this  means  the  relations  of  the  gray  nuclei  and  the  peduncular 
fibres.  The  cranial  nerve-trunks  are  to  be  carefully  noticed,  and  if  any 
suspicious  appearance  is  observed,  a  section  may  be  removed  for  micro- 
scopical examination.  The  crura  and  pons  are  to  be  examined  carefully 
for  softening,  secondary  degeneration,  extravasations  and  the  like,  and 
the  appearance  of  the  basal  parts  of  the  hemisj)heres  next  noticed.  The 
brain-substance  may  be  inspected,  in  other  ways  by  cutting  through  the  cor- 
pus callosum,  and  turning  each  hemisphere  gently  back,  or  by  slicing  oif 
the  brain -substance  with  a  broad  sharp  knife  previously  dipped  in  water  or 
alcohol,  so  that  the  white  matter  may  be  examined  at  difierent  levels,  as 
recommended  above.  The  condition  of  the  ventricles  should  be  noticed 
as  to  the  effusion  of  serum  or  blood,  or  the  condition  of  -the  lining  mem- 

^  Removal  en  masse,  of  the  brain  and  its  membranous  coverings  should  never  be 
attempted ;  the  result  of  such  a  procedure  being  mechanical  injury,  which  reduces 
the  organ  to  a  pultaceous  mass,  rendering  it  unfit  for  examination. 


20  INTRODUCTION. 

branes.  The  parts  at  the  floor  of  the  lateral  ventricles  deserve  special 
study,  and  the  corpora  striata  should  be  inspected  ver}'  attentively,  the 
extra-ventricular  and  intra-ventricular  parts  being  carefully  sliced.  A 
vertical  section  just  posterior  to  the  fissure  of  Rolando  (Pitre's  section) 
may  be  made.  The  fulness  of  the  vessels  in  the  deep  parts  of  the 
brain,  the  existence  of  patches  of  softening  or  induration,  and  the  pres- 
sure of  cysts,  tumors,  or  morliid  growths  should  be  looked  for.  It  is  al- 
ways advisable  in  cases  where  aphasia  has  been  a  symptom  during  life, 
to  carefully  inspect  the  anterior  convolutions,  particularly  the  third 
frontal,  which  is  the  generally  acknowledged  seat  of  the  lesion,  and  we 
may  do  this  examining  at  the  same  time  the  appearance  in  the  fissure  of 
Sylvius,  and  carefully  slicing  that  portion  of  the  brain  anteriorly,  and 
laterally  to  the  corpus  striatum  of  the  left  side. 

It  is  hardly  necessary  to  allude  to  the  importance  of  carefully  exam- 
ining the  medulla  and  the  roots  of  the  various  cranial  nerves,  the  pyrami- 
dal decussation,  and  the  cerebellum,  and  for  this  purpose  it  is  advisable 
to  remove  such  parts  as  are  Avauted  for  subsequent  microscopical  exami- 
nation. The  cord  must  be  examined  critically  in  cases  of  spinal  disease, 
and  the  same  directions  are  given  for  its  inspection.  Suspected  portions 
may  be  cut  out  and  laid  aside,  care  being  taken  to  secure  as  much  of  the 
external  roots  as  possible.  In  special  cases  nerve  trunks  or  peripheral 
nerves  may  be  exsected  for  future  examination,  and  in  cases  presenting 
muscular  atrophy  and  degeneration  it  is  well  to  ascertain  the  morbid 
changes  in  the  muscles.  If  we  desire  to  use  the  microscope  it  is  gener- 
ally necessary  to  harden  the  tissues,  although  fresh  nervous  substance 
may  be  teased  apart  in  glycerine  or  serum  by  needles  prepared  for  the 
purpose.  If  we  prefer  the  first  method  we  may  put  such  masses  of  the 
brain  or  cord  as  we  desire  to  harden  into  Miiller's  fluid,  which  is  prepared 

as  follows : — 

R.  Pota.ss.  bichromat.  50  grammes, 
Sodic  sulphate,  20  grammes. 
Water,  1600  grammes : 

Or,  what  is  better,  the  solution  recommended  by  Prof.  J.  W.  S.  Arnold, 
of  the   Medical    Department  of  the   University   of   the   City  of  New 

York: 

R.  Ammon.  bichromat.  11  grammes, 
Methyl  alcohol,  320  grammes, 
Water,  640  grammes. 

Care  should  be  taken  not  to  secure  specimens  which  are  too  large,  as 
they  do  not  harden  thoroughly,  the  exterior  becoming  hard  while  the  in- 
terior is  difiluent  and  useless.  They  should  be  left  in  the  solution  for  a 
month  or  six  weeks,  but  not  till  they  become  granular  or  cheesy,  for  then 
it  is  impossible  *to  make  a  good  section,  as  the  tissue  is  apt  to  crumble 
under  the  knife.  At  the  end  of  this  time,  or  when  the  tissue  is  quite  firm, 
it  may  be  removed  and  placed  in  a  fifty  per  cent,  mixture  of  alcohol  and 
water.  The  specimen  may  be  examined  to  test  its  hardness  by  making 
sections  with  a  razor  from  time  to  time.     If  a  verv  thin  section  can  be 


MICROSCOPIC    EXAMINATION.  21 

made  with  a  moistened  razor  without  parting,  adhesion,  or  crumbling,  it 
may  be  considered  to  be  in  fit  condition  for  removal  from  the  hardening 
solution.  A  solution  of  bichromate  of  ammonium,  15  grains  to  the  ounce 
of  water,  is  an  excellent  hardening  solution,  in  which  the  specimen  may 
remain  until  it  has  been  uniformly  saturated,  and  hardening  has  com- 
menced, and  then  it  is  to  be  removed  and  placed  in  a  solution  of  chromic 
acid,  two  grains  to  the  ounce  of  water,  where  it  is  to  remain  until  hard 
enough  for  cutting.  This  is  the  process  recommended  by  Dieters.  The 
specimens  may  be  taken  out  and  kept  for  use  in  dilute  alcohol  till  they 
are  needed. 

When  the  hardened  tissue  is  to  be  examined,  it  is  to  be  imbedded  in  pith 
or  paraffine,  and  either  placed  in  a  section  cutter,  or  held  in  the  hand.  By 
practice,  this  latter  procedure  becomes  quite  easy,  and  very  thin  sections 
may  be  skillfully  made.  A  piece  of  brain  or  a  length  of  cord  of  a  convenient 
size  is  surrounded  by  elder  pith  previously  prepared  to  receive  it,  and  bound 
in  place  by  a  string,  or  by  a  piece  of  fine  copper  wire.  When  moistened,  the 
pith  swells  so  that  the  tissue  receives  uniform  pressure  and  support.  If 
the  paraffine  process  be  that  employed,  the  tissue  is  to  be  carefully  dried 
and  placed  in  a  small  paper  mould  which  is  afterwards  filled  with  melted 
paraffine,  this  however  should  not  be  too  hot,^  and  care  should  be  taken 
to  exclude  air-bubbles.  When  cool  and  solid  the  upper  part  of  the  paper 
may  be  torn  away,  and  the  specimen  is  ready  for  cutting.  A  flat  razor 
is  the  best  instrument  of  which  I  know  for  ordinary  work.  Its  blade 
should  be  dipped  in  a  saucer  containing  alcohol  placed  conveniently  by, 
and  the  face  of  the  section  should  be  moistened  from  time  to  time.  The 
individual  holding  the  mould  firmly  between  the  thumb,  forefinger,  and 
second  finger  of  the  left  hand,  cuts  away  a  portion  of  mould  and  tissue 
so  that  a  level  surface  is  left  exposed ;  then,  with  moistened  razor,  he 
plants  the  blade,  and  slowly  cuts  a  thin  slice  of  paraffine  and  tissue  to- 
gether ;  this  is  removed  by  a  camel's  hair  brush  which  has  been  dipped 
in  alcohol,  and  next  dropped  into  a  small  vessel  containing  dilute  alco- 
hol, and  then  placed  in  the  staining  fluid,  which  may  be  the  follow- 
ing:— 

R.  Carmine  (pure),  gr.  xx, 

Liq.  ammonise,  q.  s.  ut  dissolv., 

Glycerin  86, 

A  quae,  aa  ^ij. — M. 

After  being  allowed  to  soak  for  several  hours  or  days,  the  sections  are 
removed  and  dropped  into  water  slightly  acidulated  with  acetic  acid. 
They  are  now  to  be  placed  in  absolute  alcohol  for  a  short  time,  and  after- 
wards in  oil  of  cloves  until  they  become  transparent.  A  perfectly 
clean  slide  is  procured,  upon  which  one  of  them  is  placed  and  a  drop  (not 
too  large)  of  Canada  balsam  is  next  applied.     It  is  then  covered  by  a  thin 

^  I  have  recently  used  metallic  bottle  caps,  which  may  be  easily  procured.  When 
the  paraffine  is  cool  the  metal  may  be  stripped  off. 


22  INTRODUCTION. 

glass  cover,  care  being  taken  to  exclude  air-bubbles.  Various  prepara- 
tions are  used  to  stain  nervous  tissue ;  for  instance,  a  solution  of  chloride 
of  gold  will  stain  the  nerve  fibres,  and  render  them  more  distinct ;  haima- 
toxylin  and  osmic  acid  are  also  used,  and  the  black  analin  process  of 
Herbert  Major^  produces  the  most  beautiful  results.  These  manipulations, 
however,  are  out  of  place  here,  and  I  would  refer  the  reader  to  any  one 
of  the  excellent  text-books  that  have  appeared  during  the  past  few  years 
for  more  explicit  directions. 

It  is  often  necessary  to  make  sections  in  all  possible  directions  and  posi- 
tions, and  to  do  this  properly  the  microscopist  must  not  only  have  practice 
but  patience  and  care.  It  is  advisable  to  procure  at  least  two  objectives, 
one  for  coarse  appearances,  and  the  other  for  minute  changes,  and  I  would 
suggest  that  these  should  be  an  "inch "  and  a  "  quarter  inch." 

INSTRUMENTS  USED  FOR  THE  DIAGNOSIS  OF  NERVOUS  DISEASE. 

It  is  essential  that  we  should  possess  certain  instruments  which  shall 
be  more  valuable  and  exact  than  our  unaided  senses,  so  that  we  may  not 
Fio-.  1.   oiily  niake  reliable  investigations,  but  compare  from  time  to 
time  such  variations  as  may  occur  in  the  patient's  condition. 

Those  I  propose  to  describe  are  intended  for  examinations  of  tem- 
perature and  sensory  changes,  and  for  the  detection  of  altered 
motility. 

The  Thermometer. — There  are  several  instruments  made  for 
the  purpose  of  determining  variations  in  temperature,  and  though 
some  are  of  extreme  delicacy,  I  do  not  think  it  will  be  worth 
while  to  recommend  them,  as  they  are  bulky  and  troublesome, 
and  are  better  adapted  for  experimental  purposes  than  actual 
clinical  use,  and  among  these  is  Lombard's  instrument. 

In  Dr.  Seguin's  surface  thermometer  we  possess  an  admirable 
little  instrument  for  testing  the  surface  temperature.  It  has  an 
expanded  base,  and  may  be  applied  to  the  surface  of  the  body, 
taking  care  to  cover  the  top  by  a  perforated  piece  of  thin  rubber 
or  leather.  A  coat  or  two  of  shellac  varnish  to  the  upper  part 
of  the  bulb  will  answer  the  same  purpose,  viz.,  that  of  prevent- 
ing the  mercury  from  being  affected  by  the  temperature  of  the 
room.  For  the  determination  of  deep  temperature  we  may 
avail  ourselves  of  any  of  the  good  self-registering  instruments. 
Two  surface  thermometers  should  be  used,  one  on  the  sound, 
and  the  other  on  the  affected  side  of  the  body,  and  the  deep 
temperature  maybe  taken  at  the  same  time  for  comparison.  A 
new  form  of  surface  thermometer  has  recently  been  made  in 
"^'^^^^  England.  The  glass  tube  is  spirally  coiled  upon  itself  and 
"^surfti'ce"^  enclosed  in  a  circular  box.  This  form  has  the  merit  of  being, 
^raeter""    Unaffected  by  other  than  the  body  temperature. 

^  West  Riding  Reports,  vol.  v. 


CEREBRAL   THERMOMETRY.  23 

Within  the  past  two  or  three  years  a  great  deal  of  interest  has  been 
excited  by  the  remarkable  investigations  of  Broca,  who  found  that  it  was 
possible  to  detect  deep  changes  of  temperature  in  the  cerebral  organs  by 
means  of  surface  thermometers  applied  to  the  exterior  of  the  cranium  ^ 
Broca's  observations  were  confirmed  by  those  of  ^  Dr.  Landon  Carter  Gray, 
of  Brooklyn,  N.  Y.,  and  by  ^Maragliano  and  Seppilli,  two  Italian  experi- 
menters. Albers  of  Bonn  was  undoubtedly  the  first  person  (1861)  to 
suggest  cerebral  thermometry ;  but  Broca's  work  was  the  first  undertaken 
in  a  systematic  and  fruitful  manner. 

By  the  use  of  six  or  more  thermometers  applied  to  the  head  at  various 
points,  with  every  allowance  for  external  disturbing  agencies  and  sources 
of  error,  it  is  found  that  the  central  temperature  undergoes  various  modi- 
fications, amounting  sometimes  even  to  several  degrees;  and  Gray  was 
enabled  to  diagnose  and  localize  the  existence  of  a  cerebral  tumor  by  this 
diagnostic  means.  The  thermometers  should  be  those  known  as  Seguin's, 
or,  better  still,  of  the  form  modified  by  Dr.  Gray.  They  should  be  tempered 
perfectly,  and  so  constructed  that  ordinary  pressure  upon  the  bulb  shall 
cause  no  rise  in  the  column  of  mercury. 

A  proper  system  of  straps  (Fig.  2),  -p-     2 

such  as  has  been  devised  by  Dr. 
Gray,  or  a  cap  of  gum-rubber,  with 
perforations,  enables  us  to  apply 
the  thermometers  upon  both  sides 
of  the  head,  over  the  points  we 
desire  to  examine.  Dr.  Gray  has 
adopted  the  names  Frontal,  Parietal, 
and  Occipital — stations  relating  to 
the  positions  indicated  by  the  names 
to  designate  the  places  over  which 

the  tests  are  to   be   made.      A   ther-  Gray's  System  of  Head  straps. 

mometer  is   to   applied  (after  the 

index  column  is  shaken  down)  to  these  spots  for  a  period  at  least 
of  twenty  minutes,  and  then  the  figures  are  read  without  remov- 
ing the  instruments.  When  a  spot  with  increased  temperature  is 
found,  the  other  thermometers  are  to  be  grouped  about  the  suspected 
locality.  Repeated  tests  show  more  or  less  sameness  in  the  readings,  so 
that  it  is  possible  to  determine  that  a  very  limited  portion  of  the  brain  is 
the  seat  of  morbid  action.  In  one  case  Gray  was  enabled  to  diagnose  a 
tumor  before  death. 


1  Progr^s  Medical,  1877,  quoted  by  Gray. 

^N.  Y.  Med.  Journal,  August,  1878,  p.  131. 

^  Eevista  Sperimentale  di  Freniatria  e  di  Medicina  Legale. 

*Tlie  adjustment  of  these  straps  should  be  made  so  that  those  passing  over  the  head 
should  go  in  front  and  behind  the  fissure  of  Eolando  which  divides  the  important  mo- 
tor tracts.  Gray  measures  from  the  fronto-nasal  fissure,  and  fixes  the  location  of  the 
fissure  as  6f  inches  posterior  to  this  point. 


24  INTRODUCTION. 

^  Dr.  Gray  thus  details  the  observations  he  made  : — 

"The  patient  was  a  female,  aged  thirty-four.  There  was  present  a 
typical  '  choked  disk,'  marked  pain  in  the  temple  and  brow,  becoming 
unbearable  in  paroxysms,  nausea,  vomiting,  ptosis,  paralysis  of  the  ocu- 
lar muscle.  The  first  paroxysm  of  pain  came  on  January  21st.  The 
bodily  temperature  ranged  near  the  normal.  Upon  these  symptoms  a 
diagnosis  of  intra-cranial  tumor  was  made,  probably  situated  at  the  base. 
Placing  my  thermometers  upon  the  head,  I  ascertained  the  temperature 
at  the  different  stations  to  be  as  follows: 

Left.  Right. 

Frontal, 96  75°  98.33° 

Parietal, 95°  99.75° 

Occipital, 96.75°  100.50° 

The  average  of  the  two  sides,  if  calculated,  will  be  found  to  be  96.16° 
on  the  left,  on  the  right  99.52°,  the  average  for  the  whole  head  being 
97.84°. 

The  rise  above  the  normal  averages  is  startlingly  apparent.  At  the 
Left  Frontal  Station  it  was  2.39°;  at  the  Left  Parietal,  56.0°;  at  the  Left 
Occipital,  4.09°;  at  the  Right  Frontal,  5.12°;  at  the  Right  Parietal, 
6.16° ;  at  the  Right  Occipital,  8.56° ;  while  the  average  of  the  left  side 
had  mounted  above  the  normal  2.33°,  the  right  side  6.QG,  and  the  average 
of  the  whole  head  4.33° ! 

This  particular  observation  was  taken  as  I  was  at  the  outset  of  my 
study  of  the  subject,  and  was  made  with  my  first  set  of  thermometers, 
which,  as  I  have  already  stated,  were  defective.  I  have  satisfied  myself, 
however,  that  the  defect  amounted  to  but  a  little  over  one  degree.  If, 
therefore,  from  these  figures  one  and  a  half  degree  be  deducted,  all  fear 
of  error  may  be  dismissed;  and  yet  the  increase  is  unmistakable.  About 
this  date  (March  4th),  I  wrote  Dr.  Rockwell :  "I  shall  certainly  expect 
to  see  inflammatory  changes  from  the  base  of  the  fissure  of  Sylvius  back- 
ward along  the  occipital  lobe,  as  well  as  that  these  changes  shall  be  spread 
around  the  base  of  the  fissure."  The  patient  died  March  16th.  * 
*****"  The  meninges  were  found 
apparently  normal,  with  the  exception  of  a  slight  congestion.  At  the 
base  of  the  brain  the  membranes  and  skull  were  to  all  appearances 
healthy.  But  a  soft,  jelly-like  tumor,  the  size  of  a  hazel-nut,  was  found 
between  the  horizontal  or  posterior  branch  of  the  fissure  of  Sylvius  and 
the  first  temporal  fissure,  while  the  whole  of  the  right  occipital  lobe  was 
converted  into  a  colloid,  extremely  vascular  mass,  which  gave  way  under 
examination,  this  degeneration  also  extending  anteriorly  to  the  tumor  as 
far  as  the  fissure  of  Sylvius.  There  was  no  apparent  disease  except 
at  these  points.  Upon  microscopical  examination,  I  ascertained  the 
tumor  to  be  a  typical  glioma,  thickly  strewn  with  small  extravasations  of 
blood." 

Dr.  Chas.  K.  Mills  ^  has  reported  an  interesting  case  of  tumor  of  the 

1  Loc.  cit.  ^  Phil.  Med.  Times,  Jan.  18,  1879. 


^STHESIOMETEK. 


25 


brain,  involving  portions  of  the  first  and  second  frontal  convolutions,  in 
which  he  found  that  the  temperature  obtained  over  the  middle  frontal 
station  averaged  1.50°  above  that  of  the  other  stations. 

The  evidence  collected  by  the  few  observers  already  mentioned  shows 
the  normal  average  temperature  to  be  about  as  follows  at  the  stations 
designated : 


K.   Frontal  . 

L. 

E.  Parietal  . 

L.         "        . 

E,.  Occipital 

L.        " 


93.71° 
94.36° 


93.59  , 
94.44. 
91.94 , 
92.66° 


MARAGLIANO  AND 
SEPPILLI. 


97.07  , 

,97.16, 
97.07  , 


.97.12. 
.96.71. 
.  96.81 . 


BROCA. 


95.39 
95.79 
92.84 
91.49 

92.66 


N.  B.  The  experiments  of  Gray  and  Broca  were  made  during  cool  weather. 

Gray  found  the  average  temperature  on  the  left  side  of  the  head  to  be 
93.83°  ;  right,  92.92°.  The  average  temperature  of  the  whole  head,  ex- 
clusive of  the  vertex,  93.51°.  Average  temperature  of  motor  region  of 
vertex,  91.67°.     His  conclusions  may  be  summed  up  as  follows  : 

"  If  there  be  an  alteration  of  temperature  at  any  of  the  lateral  stations 
of  more  than  one  and  a  half  degree  above  or  below  the  average  tempera- 
ture of  such  station,  this  fact  will  justify  a  suspicion  of  abnormal  change 
at  that  point. 

"If  there  be  an  alteration  of  temperature  at  any  of  the  lateral  stations 
of  more  than  two  degrees  above  or  below  the  average  of  such  station,  this 
fact  will  constitute  strong  evidence  of  the  existence  at  this  station  of  ab- 
normal change. 

"  In  proportion  as  the  alteration  of  temperature  at  any  individual  sta- 
tion is  increased  or  decreased  beyond  the  figures  just  mentioned,  in  exact 
proportion  will  the  strength  of  the  evidence  be  increased  as  to  the  exist- 
ence of  abnormal  change  at  that  station,  until,  the  maximum  or  mini- 
mum having  been  passed,  the  evidence  will  become  almost  conclusive. 

"  Should  it  so  happen  that  such  elevation  of  temperature  above  the 
average  should  be  at  any  lateral  station  on  the  right,  causing  a  rise  at 
this  point  beyond  the  average  temperature  at  the  corresponding  station 
on  the  left,  this  would  strengthen  the  suspicion  or  the  evidence." 

My  own  observations  have  been  but  few  in  number,  though  I  trust  I 
shall  soon  be  able  to  add  to  Dr.  Gray's  valuable  collection  of  facts. 

In  one  case  of  undoubted  cerebral  tumor  under  my  charge  there  is  a 
rise  of  temperature  of  three  degrees,  which  does  not  even  vary  a  degree 
though  I  have  made  over  thirty  examinations  under  all  sorts  of  circum- 
stances. In  one  case  of  chronic  cerebral  meningitis,  there  was  a  general 
rise  of  cranial  temperature,  which  was  highest  at  the  vertex,  however. 

The  .^STHESiOMETER  was  first  suggested  by  Sieveking,  and  has  since 
been  modified  by  different  individuals.     We  have  several  different  varie- 


26 


INTRODUCTION. 


ties  to  choose  from,  but  no  one  is  better  than  the  original  instrument  of 
Sieveking,  which  is  also  used  and  recommended  by  Brown-Sequard.  It 
is  made  of  brass  or  steel,  and   very  closely  resembles  a  shoemaker's  mea- 

Fig.  3. 


Sieveking's  ^sthesiometer. 


sure.  The  movable  slide  and  permanent  arms  at  the  end  are  sharp- 
pointed.  The  bar  upon  which  the  free  slide  moves  is  ruled  in  centi- 
meters. 

The  other  sesthesiometers  are  mostly  shaped  like  dividers,  and  are  open  to 
the  objection  that  the  points  are  liable  to  be  unconsciously  approximated 
when  the  instrument  is  removed,  so  that  the  result  of  investigation  is 
somewhat  unreliable.  Carrol's  jesthesiometer  has  one  advantage.  The 
points  are  bifurcated,  one  arm  ending  in  a  bulb,  while  the  other  is  sharp, 
so  that  analgesia  as  well  as  anaesthesia  may  be  tested. 


^STHESIOMETER.  27 

Dr.  E.  C.  Seguia  has  made  a  very  decided  improvement  upon  the 
original  instrument  of  Sieveking.  He  has  had  it  constructed  of  alumi- 
num, and  of  a  smaller  size,  so  that  it  is  light  and  small,  and  may  be 
easily  carried  in  the  pocket-ease. 

The  principle  upon  which  the  sesthesiometer  is  constructed  is  the  fol- 
lowing :  The  normal  receptivity  of  tactile  impressions  enables  the  subject 
to  distinguish  two  points  which  are  brought  simultaneously  in  contact 
with  the  skin.  This  susceptibility  varies  greatly  in  different  regions  in 
proportion  to  the  delicacy  of  the  tactile  sensation  located  therein.  If 
there  be  loss  of  sensation  as  an  accompaniment  or  result  of  nervous  dis- 
ease, of  course  the  distance  between  them  will  have  to  be  increased  be- 
fore the  points  will  be  felt  as  two.  In  hypersesthesia  they  may  be  much 
more  nearly  approximated  and  distinguished  as  two  than  in  the  anaesthe- 
tic state. 

The  average  distance  at  which  the  two  points  of  the  instrument  can  be 
felt  in  the  normal  state  are  as  follows  : — 

Point  of  tongue ^  line 

Red  surface  of  lips 2  lines 

Palmar  surface  of  third  finger 1  line 

Tip  of  nose 3  lines 

Metacarpal  bone  of  thumb 4     " 

Skin  of  cheek 5     " 

Mucous  membrane  of  hard  palate 6     " 

Dorsal  surface  of  first  finger 7     " 

Dorsum  of  hand  over  heads  of  metacarpal  bones 8     " 

Mucous  membrane  of  gums 9     " 

Lower  part  of  forehead 10     " 

Lower  part  of  occiput 12     '' 

Back  of  hand 14     " 

Neck  under  lower  jaw 15     " 

Vertex 15     '' 

Skin  over  the  patella 16     " 

Skin  over  the  sacrum 18     '' 

Skin  over  the  sternum 20     '' 

Skin  over   cervical  vertebrae 24     " 

Skin  over  middle  of  back 30     " 

Skin  over  middle  of  the  arm 30     " 

Skin  over  middle  of  the  leg 30     " 

Certain  precautions  must  be  taken  when  using  the  sesthesiometer,  or 
else  our  examination  will  be  unsatisfactory  in  the  extreme ;  we  must  not 
depend  in  all  cases  upon  the  patieot's  statement,  but  exercise  tact  in  get- 
ting from  him  satisfactory  answers,  and  not  guesses.  There  seems  to  be 
in  some  individuals  a  discouraging  stupidity  which  prompts  them,  in  an- 
swer to  the  question,  "  How  many  points  do  you  feel  ?  "  to  oftentimes  re- 
ply "  Three,"  when  they  know  that  the  instrument  has  but  two  points. 
It  is  of  the  greatest  importance  that  the  patient's  eyes  should  be  covered 
or  that  he  should  close  them,  as  he  will  unconsciously  look  at  the  instru- 
ment during  its  application.  It  is  also  of  moment  that  the  points  should 
be  fairly  and  at  the  same  time  applied  to  the  skin,  one  not  being  pressed 


28 


INTRODUCTION. 


more  than  the  other,  and  finally,  it  may  be  stated  that  they  should  not  be 
applied  at  any  place  where  the  clothing  has  rubbed  or  chafed  the  surface. 


Diagram  for  making  Records. — Roman  numerals  show  ancestlietic  indications,  the 
others  normal  sensibility. 

Since  the  appearance  of  the  first  edition  of  this  book  Dr.  Hughes,  of 
St.  Louis,  has  devised  a  very  convenient  instrument,  a  new  feature  being 
an  ingenious  scale  of  measurements  upon  its  bar,  with  a  standard  for 
reference. 

Various  tests  of  sensibility  are  simpler  than  those  of  the  kind  I  have 
described.  For  gross  tests  the  finger  tips  of  the  examiner  may  be  applied 
and  separated  like  compass  arms.  Shape  and  pressure  may  be  deter- 
mined by  the  application  of  various-sized  bodies,  weights,  or  coins,  the 
subject's  eyes  being  meanwhile  bandaged. 

The  Dynamometer. — Various  forms  have  been  devised,  that  in  general 
use  being  invented  by  Burq  and  introduced  by  Mathieu.  It  consists  of  an 
elliptical  spring,  Avhich,  when  compressed  in  the  hand,  registers  upon  an  in- 
dex the  force  exerted.  When  the  needle  is  forced  ahead  it  remains  at  the 
point  it  had  reached  when  pressure  was  remitted,  and  the  spring  expands. 
Its  disadvantage  lies  in  the  inequality  of  pressure  made  at  diflTerent  times, 
the  bulky  character  of  the  apparatus,  and  its  inadaptability  to  other  uses. 


THE   DYNAMOMETER. 


29 


Fig.  5. 


»«-fi£  YNO£13.i. -^ 

Mathieu's  Dynamometer. 


Having  recognized  the  necessity  for  an  instrument  that  would  meet  the 
therapeutical  requirements  not  possessed  by  those  of  Mathieu  or  Du- 
chenne,  I  have  devised  that  figured  in  the  appended  illustration.  It  con- 
sists of  a  long  glass  tube  (2)  which  dips  into  a  small  bottle  filled  with 
mercury.  In  connection  with  a  bent  brass  pipe  (3)  is  a  rubber  tube 
which  terminates  in  a  closed  rubber  bulb  (5  \  When  this  bulb  is  com- 
pressed the  mercury  is  forced  up  in  the  glass  tube,  the  end  of  which  is 
closed.  Attached  to  the  tube  is  a  scale  (1)  registered  on  one  side  in  pounds, 
and  on  the  other  by  marks  separated  by  regular  intervals  for  the  purpose 
of  making  comj)arative  estimates.  As  fifteen  pounds'  pressure  to  the 
square  inch  is  required  to  compress  a  given  body  of  air  into  one-half  its 
original  space,  of  course  a  force  of  fifteen  pounds'  pressure  brought  to 
bear  upon  the  bulb  would  be  required  to  press  the  column  of  mercury 
halfway  up  the  scale.  The  advantages  of  this  apparatus  are  the  follow- 
ing:— 

1.  Its  simplicity. 

2.  The  adaptability  of  the  rubber  bulb  to  receive  pressure  exerted  by 
all  the  flexors  of  the  hand.  Mathieu's  spring  is  only  acted  upon  by  a  limited 
number ;  at  the  same  time,  therefore,  the  test  is  not  a  true  one. 

3.  The  action  of  the  muscles  is  the  same  at  difiTerent  times.  The  same 
group  of  muscles  always  being  brought  into  play,  accurate  comparative  tests 
may  be  made  from  day  to  day. 

4.  The  part  receiving  the  pressure  is  of  a  convenient  shape  to  be  used 
by  persons  with  either  small  or  large  hands. 

5.  It  is  accurate  and  always  gives  reliable  indication  of  the  pressure 
brought  to  bear. 

Dr.  Birdsall  of  this  city  has  recently  invented  a  most  ingenious  foot 
dynamometer  for  testing  the  strength  of  the  lower  extremities. 

The  dynamometer  is  at  best  an  instrument  of  questionable  value,  as  are 
others  requiring  an  effort  upon  the  part  of  the  patient.  In  rough  tests  of 
power  it  is  useful,  but  in  accurate  case-taking,  very  little  importance  can 
be  attached  to  the  detailing  of  small  variations  as  recorded  upon  the  dial 
or  scale  of  any  dynamometer. 

I  have  combined  the  rubber  bulb  with  the  drum  of  Marey,  and  am 
enabled  to  obtain  gro'ss  variations  with  tolerable  accuracy.     The  drum  has 


30 


INTRODUCTION. 


two  pipes,  one  of  which  is  connected  with  the  rubber  bulb,  while  another 
is  attached  to  the  lower  end  of  an  open  glass  tube.     The  bulb-drum  cavity 

Fig.  6. 


The  Author's  Dynamometer. 

and  a  part  of  the  tube  are  filled  with  colored  fluid,  so  that  the  fluid  in  the 
latter  reaches  a  mark  at  about  the  middle  of  its  length.  The  patieut  grasps 
the  bulb  and  makes  enough  pressure  to  force  the  fluid  in  this  tube  to  a  mark 
slightly  above  the  other.  The  sustained  voluntary  effort  required  to  keep 
the  fluid  at  this  point  necessitates  some  delicacy  of  muscular  co-ordination, 
and  should  this  be  impaired  there  will  be  expansion  of  the  drum-head  and 
consequently  irregular  tracings  upon  the  cylinder  of  the  registering  appa- 
ratus. This  cylinder  should  be  covered  by  a  piece  of  smoked  paper,  and 
the  stylet  placed  in  apposition  thereto. 

In  alcoholic  tremor,  commencing  sclerosis,  and  the  metallic  tremors,  we 
may  obtain  very  beautiful  tracings. 

The  Ophthalmoscope. — The  parts  composing  the  ordinary  ^ophthal- 
moscope are  the  following :  A  concave  mirror  perforated  at  its  centre,  a 
series  of  lenses  by  which  the  refraction  in  the  subject's  or  observer's  eye 


THE   OPHTHALMOSCOPE. 


31 


may  be  corrected,  and  a  bi-convex  lens  The  three  forms  in  common  use 
are  those  of  Liebreich,  Loring,  and  Knapp.  The  two  latter  are  essentially- 
alike  in  construction,  and  the  first  is  quite  primitive,  usually  of  bad  con- 
struction, and  quite  unreliable. 

Fig.  7. 


Loring's  Ophthalmoscope. 

In  the  examination  with  this  instrument  great  care  should  be  taken  by 
the  observer  to  determine  whether  he  or  his  subject  possesses  errors  of  re- 
fraction, and  if  so,  to  correct  them  with  the  proper  lenses.  In  the  modern 
ophthalmoscope  a  number  of  lenses  are  held  in  a  revolving  disk  behind 
the  mirror. 

For  more  specific  directions  the  reader  is  referred  to  Dr.  Loring's  ad- 
mirable little  work.^ 

To  examine  the  eyes  of  a  patient  properly,  the  observer  may  follow  the 
concise  directions  laid  down  by  Hutchinson.^ 

"  Having  placed  the  patient's  head  in  such  a  manner  that  the  light  (a 
lamp,  candle,  or  gas-light)  is  on  a  level  with  his  temple,  and  slightly  be- 


1  Determination  of  Errors  of  Refraction  with  the  Ophthalmoscope.     E.  G.  Loring. 
Wm.  Wood  &  Co.,  N.  Y. 
'■^  Jonathan  Hutchinson.     Clinical  Reports  of  London  Hospital,  1867 — 8,  p.  182. 


32 


IXTRODUCTIOX 


hind  it,  and  his  face,  as  a  consequence,  in  shadow,  the  observer  sits  in 
front  and  applies  the  ophtlialmoscope  mirror  to  his  own  eye.  He  should 
keep  both  eyes  open  that  he  may  see  where  the  light  falls,  and  then  move 
the  mirror  until  the  light  falls  full  on  the  pupil  of  his  patient.  In  a  mo- 
ment he  will  perceive  the  first  fact  which  this  instrument  reveals,  that  the 
fundus  is  not  black,  as  it  has  always  appeared  to  be  before,  but  that  it  is 
of  a  brilliant  fire-red.  He  will,  however,  see  nothing  of  the  fundus  dis- 
tinctly, only  a  general  red  reflex.  Now  at  this  point  the  student  must 
stop  awhile  and  use  his  mirror,  to  inspect,  first,  the  transparency  of  the 
cornea,  and,  next,  that  of  the  lens  and  vitreous,  and  to  do  this  he  must 
make  the  patient  move  his  eye  in  various  directions.  After  a  little  prac- 
tice he  will  be  able  to  manage  his  light  well,  and  to  throw  it  with  preci- 
sion wherever  he  may  wish,  and  to  keep  it  steadily  on  any  given  part.  At 
a  first  lesson  he  may  even,  with  advantage,  practise  for  a  while  by  illumi- 
nating the  second  button  of  the  patient's  waistcoat.  Tact  in  directing  the 
light  having  been  obtained,  we  may  now  proceed  further.  Instruct  the 
patient  to  look,  not  full  in  your  face,  but  over  one  shoulder  ;  if  you  are 
inspecting  his  right  eye,  over  your  left  shoulder.  You  will,  when  he  does 
this,  notice  at  once  that  the  tint  of  the  light  reflected  from  his  fundus  is 
changed,  that  it  is  no  longer  fire-red,  but  canary  yellow.  The  reason  of 
this  is  that  a  difl^erent  part  of  the  fundus  is  exposed  to  view,  that,  namely, 
of  the  optic  disk  itself,  which  is  much  lighter  in  color  than  the  rest.  The 
area  of  yellow  is  very  large — occupies,  indeed,  the  whole  of  the  field, 
while  we  know  that  the  disk  itself  is  very  small.  This  proves  that  the 
objects  thus  indistinctly  seen  are  immensely  magnified.  Magnified  by 
what?  By  the  patient's  own  eye,  which,  as  we  have  said, is  equivalent  to 
a  lens  of  one  inch  focus. 

"  Hitherto  we  have  seen  nothing  distinctly,  but  if  the  observer  now 
brings  his  head  very  close  to  his  patient's  face,  he  will  be  able  with  more 
or  less  facility  to  observe  the  details  at  the  bottom  of  the  eye,  the  trunks 
of  vessels  of  the  retina,  the  optic  disk,  etc ,  etc.  All  these  will  be  seen 
very  large  indeed,  being  still  magnified  by  the  patient's  eye.  What  he 
sees  now  is  equivalent  to  type  looked  at  through  a  one-inch  lens,  placed 
exactly  one  inch  in  front  of  it." 

Without  entering  into  an  extended  discussion  as  to  tho  value  of  this 

Note. — Dr.  Loring  says,  in  concluding  an  admirable  paper  :  "  By  the  experiments 
considered  in  the  foregoing  remarks  two  alternatives  are  forcibly  presented  to  our 
mind:  either  that  the  circulation  of  the  eye  is  not  a  reflex  of  the  circulation  of  the 
brain,  though  derived  directly  from  it ;  and  thus  agents  which  affect  profoundly  the 
one  have  little  or  no  influence  on  the  other;  or,  if  the  retinal  circulation  is  a  reflex 
of  the  cerebral,  it  follows  that  the  influence  exerted  on  the  circulation  of  the  brain  by 
agents  at  our  command,  remedial  or  otherwise,  is  very  much  less  than  heretofore 
supposed. 

"  I  cannot  but  think  that  the  former  alternative  is  the  more  rational,  and  from  that 
very  independence  of  the  two  circulations  there  is  reason  to  fear,  so  far  as  functional, 
and  especially  mental  diseases,  are  concerned,  that  there  never  will  be,  any  more 
than  there  now  is,  any  art  to  read  the  mind's  construction  in  the  eye." 


THE    PERCUSSION     HAMMER. 


33 


Fis.  8. 


instrument  as  a  means  of  diagnosis,  it  will  be  well  to  state  frankly  that  I 
do  not  believe  that  it  possesses  any  positive  value  in  the  diagnosis  of  brain 
disease,  except  ivhere  the  condition  of  the  fundus  is  the  result  of  an  organic 
disease  of  the  brain  or  cord,  or  when  it  is  possible  to 
connect  such  disorders  with  errors  in  refraction. 

In  making  this  statement  I  s-hall,  perhaps,  find 
many  opponents,  but  I  nevertheless  have  many 
powerful  allies. 

Bouchut,^  Panas,-  Albutt,"*  Bull,  and  others  have 
written  extensively,  and  have  furnished  a  large 
number  of  clinical  reports  of  ophthalmoscopic 
changes  co-existent  with  cerebral  tumors,  menin- 
gitis, softening,  efi'usion,  cerebral  hemorrhage,  gen- 
eral paralysis,  locomotor  ataxia,  and  other  forms 
of  sclerosis,  epilepsy,  and  the  syphilitic  and  ursemic 
neuroses.  Hutchinson,'*  of  Philadelphia,  in  an 
admirable  article,  gives  many  of  these  cases,  and 
shows  the  real  value  of  the  ophthalmoscope,  espe- 
cially when  an  examination  of  the  fundus  reveals 
choked  disk  and  optic  neuritis,  but  I  will  speak 
more  fully  in  regard  to  this  subject  when  we  come 
to  the  discussion  of  special  diseases. 

My  friend  Dr.  Buzzard,  of  London,  demonstra- 
ted to  me  at  the  National  Hospital  for  the  Epi- 
leptic and  Paralyzed,  a  useful  application  of  the 
ophthalmoscope,  for  the  purpose  of  testing  the  sen- 
sibility of  the  iris.  The  patient  sits  in  a  dimly- 
lighted  room  and  looks  at  some  object  at  a  distance, 
so  that  the  pupil  is  not  contracted  in  accommoda- 
tion. A  pencil  of  light  is  then  thrown  upon  the 
eye-ball  to  one  side  of  the  pupil,  and  gradually 
changed  in  direction,  so  that  the  iris  is  suddenly 
stimulated.  Erb  prefers  for  this  test  the  use  of  arti- 
ficial light  concentrated  by  a  convex  lens. 

The  Percussion  Hammer — For  the  purpose  of 
rapping  the  patellar  or  other  tendons,  the  ordi- 
nary percussion  hammer  with  a  rubber  head,  such 
as  is  ordinarily  used  by  medical  men  in  chest 
examinations,  has  been  adopted. 

One  with  a  flexible  whalebone  handle  is  the  best. 
The  patient  seats  himself  with  both  feet  upon  the  ground,  with  bared 

1  Du  Diagnostic  des  Maladies  du  Systeme  Nerveux  par  I'Oplithalinoscope.     Paris, 
1876. 
^  La  France  Medicale,  Feb.  26,  1876. 
^  Med.  Times  and  Gaz.,  vol.  i.,  p.  495,  and  seq. 
♦Phil.  Med.  Times,  May  8,  1875. 

3 


Percussion  Haramer. 


34 


INTRODUCTION. 


legs  and  a  smart  blow  is  then  struck  just  below  the  patella,  with  the  effect 
of  producing  the  "  tendon  reflex  "  movement.  A  sharp  contraction  of 
the  quadriceps  femoris generally  occurs  in  the  healthy  person,  and  a  more  or 

less  violent  extension  of  the  leg  follows.  This 
method  of  procedure  may  be  resorted  to,  or 
the  patient  may  cross  his  legs,  and  the  ex- 
aminer may  tap  the  tendon  of  the  depen- 
dent knee. 

The  position  of  the  limb  should  never  be 
constrained  or  uncomfortable,  and  there 
must  be  no  voluntary  contraction  of  the 
muscle  upon  the  jDart  of  the  patient.  In 
cases  where  there  is  unusual  excitability 
of  the  "  tendon  reflex "  the  blow  may  be 
struck  upon  the  tibia.  In  fat  persons  the 
patient's  leg  may  be  supported  upon  the 
arm  of  the  examiner,  as  figured  in  the  an- 
nexed illustration.  This  subject  will  in 
another  part  of  this  work  be  alluded  to 
more  fully.  (See  "Diseases  of  the  lateral 
columns,  etc.") 


Producing  the  "  tendon  refiex  " 
movement,    (tiower.) 


APPARATUS  FOR  THE  TREATMENT  OF  KERVOUS 
DISEASE. 

Electrical. — Two  forms  of  apparatus  are  required^ — one  for  the  pro- 
duction of  galvanic,  the  other  for  the  induced  or  Faradic  current — as 
well  as  the  necessary  electrodes. 

As  we  know,  the  galvanic  current  is  derived  directly  from  a  battery 
or  pile,  the  first  consisting  of  two  elements,  which  are  contained  in  a 
vessel  filled  with  some  exciting  solution,  and  the  latter  of  plates  of  metal 
placed  one  above  the  other,  and  separated  by  disks  of  felt  or  paper 
moistened  with  a  solution  of  salt  or  acid.  This  last  apparatus  is  rarely 
used. 

One  vessel  or  cell  of  the  form  I  have  first  described  constitutes  a 
simple  battery,  and  two  or  more,  with  the  poles  alternately  connected,  a 
compound  battery. 

Two  qualities  of  electric  force  are  generated  by  a  battery  of  this  kind  : 
1.  Quantity;  2.  Intensity.  The  latter  is  the  characteristic  which  makes 
it  valuable  as  a  means  for  the  production  of  muscular  contraction  and 
nerve  stimulation. 

The  Faradic  current  is  derived  from  a  galvanic  cell  primarily,  and  is 
developed  by  its  passage  through  a  coil  of  wire  wound  about  a  central 
core  or  bundle.  Two  currents  are  induced  therein  :  one  the  primary 
induced,  the  other  the  secondary  induced.  The  first  is  less  ccarse  and 
vi  )lent  in  its  effects  than  the  other. 

For  a  more  extended  description  of  electro-physics,  physiology,  and 


RUBBER   MUSCLES,    ETC.  35 

therapeutics,  I  would  refer  the  reader  to  any  of  the  works  mentioned  at 
the  foot  of  this  page.  ^ 

For  the  production  of  the  galvanic  current,  we  may  avail  ourselves  of 
either  one  of  the  permanent  batteries ;  the  cells  of  which  may  be  set  up 
in  the  cellar,  and  the  wires  carried  to  a  proper  board  in  the  ofiBce, 
containing  apparatus  for  their  selection  ;  or  we  may  use  the  ordinary 
portable  galvanic  battery,  many  styles  of  which  are  made. 

I  have  given  the  Leclanche  battery  a  fair  trial,  and  now  do  not 
recommend  it,  as  it  is  dirty,  inconstant,  and  rapidly  loses  power.  The 
"  magazine  battery  "  of  Chester,  in  which  the  peroxide  of  lead  is  substi- 
tuted for  the  black  oxide  of  manganese  in  the  porous  cell,  is  much  better. 
The  old  Daniel's  cell  is,  I  am  convinced,  the  best  of  all,  and  whether  in 
the  form  of  the  Siemens  and  Halske,  or  Hill  modification,  is  all  that  can 
be  desired. 

The  table  board  of  Fleming  of  Philadelphia,  or  the  arrangement 
known  as  the  ''  cabinet  battery,"  which  is  made  by  the  Galvano-Faradic 
Company  of  New  York,  is  admirable  for  ofBce  use. 

The  Faradic  instrument  should  be  provided  with  an  attachment  for 
the  slow  or  rapid  interruption  of  the  current,  an  addition  to  the  ordi- 
nary battery,  which  will  be  found  of  immense  advantage  in  certain  forms 
of  paralysis.  The  instruments  of  the  two  firms  I  have  mentioned,  be- 
sides those  of  Drescher  and  Kidder,  are  all  good. 

Two  or  three  cotton-cloth  covered  electrodes  of  difi^erent  sizes,  or  fiat 
sponges  with  rubber  backs,  with  fine  wire  pole  cords  instead  of  the  flimsy 
gold-thread  connections  in  present  use,  which  oxidize  and  break,  will  be 
needed,  as  well  as  a  bundle  of  fine  wires  held  in  a  handle,  which  is 
known  as  an  electric  brush.  Static  electricity  has  lately  received  some 
attention.  Beyond  its  moral  eflTect  upon  the  patient,  especially  if  there 
be  hysteria,  I  do  not  believe  that  it  possesses  any  advantages  over  the 
chemical  currents. 

KuBBER  Muscles,  etc. — Dr.  Van  Bibber,  of  Baltimore,  has  devised 
a  very  useful  apparatus  for  the  treatment,  especially  of  lead  paralysis. 
It  consists  of.  a  strap  for  the  hand  or  other  part  which  needs  support, 
and    one  for  a   point  of  attachment  of  the  muscle.      When    properly 

Either  of  these  works  will  be  found  practically  useful  to  the  student : — 
Tibbit's  Handbook  of  Medical  Electricity. 
Beynolds'  Clinical  Uses  of  Electricity. 
Althaus's  Electricity,  Theoretical  and  Practical. 
Poore :  A  Text  Book  of  Electricity,  etc. 
Lincoln's  Electro-Therapeutics. 

Beard  and  Rockwell's  Medical  and  Surgical  Electricity. 
Hamilton's  Clinical  Electro-Therapeutics. 
Duchenne's  de  1' Electrisation  localise,  1872. 
Onimus  et  Legros,  Traite  D' Electricity  Med. 
Benedikt  Electrotherapie,  1874-5. 
Ziemssen,  Die  Electricitat  in  der  Med.,  1872. 
Besides,  the  works  of  Rosenthal,  Erb,  Meyer,  Eulenburg,  and  others. 


36 


INTRODUCTION, 


applied,  the    rubber    pipe,  which    takes    the   place  of    the   paralyze 
Iscle,  raises  the  hand,  so  that  the  strain  upon  the  enfeebled  muscle  i 
relieved.     Dr.  Van  Bibber  has  also  used  court  plaster  for  the  treatment 
of  ptosis  and  other  minor  paralysis. 

The  Hypodermic  Syringe,  Ether  Spray  Apparatus,  and  Spinal 
and  Cranial  Ice  Bags,  should  be  procured  by  every  physician  who  has 
occasion  to  treat  this  class  of  diseases. 

CAUTERiES.-Until  a  few  months  ago  the  old  forms  of  cautery  were 
used  almost  exclusively.  These  are  of  iron,  and  are  sometimes  platma 
covered.  When  needed,  they  are  heated  in  the  flame  of  a  Bunsen 
burner,  Russian  blast  lamp,  or  some  such  contrivance,  but  lose  their  heat 
very  rapidly,  and  generally  assume  a  dead  red  color  when  applied,  ihe 
glass  rods,  heated  in  a  like  manner,  though  somewhat  more  convenient, 
become  very  quickly  cool.  ^        ^  ,,      a         •     ^ 

Dr.  J.  J.  Putnam,  of  Boston,  exhibited  at  a  meeting  of  the  American 


Fig.  10. 


The  Author's  Gas  Cautery. 


Neurological  Association  the   first   gas    cautery  seen  in    this    country, 
though  Alex.  Bruce   years  ago  invented  a    cautery  of  this  kind,      it 


CAUTERIES.  37 

was  constructed  in  such  a  manner  that  the  jet  of  an  ordinary  gas  blow  pipe 
was  directed  upon  a  cup  of  platinum.  Its  advantages  over  the  older 
variety  were  manifold,  but  it  possessed  faults  I  have  tried  to  remedy  in 
a  modification. 

The  advantages  of  this  instrument  are  the  following : — 

1.  The  jet  which  prevents  all  hissing  or  noise,  and  still  produces  a  very 
powerful  blast. 

2.  The  apron  of  wire  gauze,  which  prevents  the  return  of  flame,  thus 
obviating  the  danger  of  burning  parts  that  we  do  not  wish  to  affect. 

3.  The  large  bag,  which  acts  as  a  reservoir,  so  that  the  operator  need 
not  use  the  rubber  bulb  nor  watch  the  burner  after  it  is  filled. 

4.  The  hook,  which  enables  him  to  suspend  the  bag  and  tubing  from 
his  person,  thus  removing  all  drag. 

The  general  advantages  of  this  form  of  cautery  are  important.  A 
uniform  heat  may  be  kept  up  for  hours  with  very  little  exertion.  The 
furnace,  which  is  not  only  inconvenient,  dirty,  and  alarming  to  timid 
people,  but  is  a  slow  method,  is  done  away  with.  In  less  than  a  minute 
the  platinum  dome  can  be  heated  to  whiteness. 

The  cauteries  of  Pacquelin  and  Guerard,  of  Paris,  are  both  good.  In 
them  the  vapor  of  benzine  (which  should  be  impure)  is  forced  with  air 
upon  a  piece  of  hot  platinum.  These  are  excellent  substitutes  for  the 
cautery  I  have  just  described,  especially  in  the  country,  where  there  is  no 
gas.  Messrs.  Stohlman,  Pfarre  &  Co.  have  constructed  for  me  an  appara- 
tus which  consists  of  the  cautery,  handle,  and  a  hard  rubber  receptacle 
containing  charpie  which  is  to  be  saturated  with  benzine.  There  is  no 
danger  of  explosions  such  as  exist  when  we  use  the  ordinary  bottle  that 
forms  a  part  of  the  French  instrument. 

It  has  been  recommended  that  the  spinal  ether  spray  be  used  to  deaden 
pain  ;  but  not  only  is  there  danger  of  an  explosion  when  this  procedure 
is  tried,  but  it  seems  to  me  that  the  very  object  of  the  operation,  revul- 
sion, is  not  accomplished,  as  the  peripheral  filaments  are  of  necessity  be- 
numbed. 


38  DISEASES   OF   THE   CEREBRAL   MENINGES. 


CHAPTER  I. 

DISEASES  OF  THE  CEREBRAL  MENINGES. 

All  of  the  investing  membranes  of  the  brain  may  be  the  seat  of  in- 
flammatory action,  but  it  is  almost  impossible  in  certain  instances  to  make 
distinctions  between  inflammation  of  the  arachnoid  and  pia  mater,  though 
this  has  been  attempted  by  Parent-Duchatelet,  Lallemand,  and  others. 
"We  will,  therefore,  have  to  content  ourselves  with  a  division  founded  upon 
the  duration,  intensity,  and  coexisting  diseases  of  the  general  system,  and 
limit  our  regional  diagnoses  to  forms  which  may  be  called  meningitis  of 
the  convexity  and  meningitis  of  the  base. 

In  respect  to  certain  circumstances  which  modify  the  appearance  of  the 
disease  we  may  divide  its  varieties  as  follows  : — 

Cerebral  pachymeningitis,  )  p,       '. 

(Inflammation  of  the  dura  mater,)       /  „,        ,  '     .  ,   . 

V  Chronic,  with  hematoma. 

r  Basilar, 
Acute  cerebral  meningitis,  •)  Of  the  convexity, 


\.  Granular. 


Chronic  cerebral  meningitis. 


PACHYMENINGITIS  (INFLAMMATION  OF  THE  DURA). 

Two  forms  of  pachymeningitis  are  to  be  met  with,  one  of  which  is  acute 
and  is  the  direct  result  of  injury  or  disease  of  the  cranial  bones,  and  is 
generally  fatal  in  a  short  time;  and  the  other,  of  a  chronic  nature,  which 
may  either  remain  after  injury,  or  arise  from  some  intracranial  cause,  or 
perhaps  be  the  result  of  general  disease,  or  old  age. 

ACUTE    PACHYMENINGITIS. 

Symptoms. — After  the  traumatism,  or  when  the  external  disease 
has  invaded  the  intracranial  cavity,  the  first  symptom  is  usually  severe  and 
localized  pain,  which  finally  extends  with  the  inflammation,  and  becomes 
diflfused  over  the  entire  head. 

Rigors,  alternating  with  elevation  of  tempei'ature,  which  may  sometimes 
attain  105°  or  106°  F.,  head  pain  and  occasionally  spasms  of  the  arms  or 
legs,  are  ordinary  symptoms ;  and  if  the  condition  be  a  very  acute  one, 
there  may  be  general  convulsions,  or  perhaps  a  partial  paralysis,  which 
is  unilateral. 


ACUTE    PACHY3IENIXGITIS.  39 

Delirium  usually  supervenes  in  from  three  days  to  a  week,  and  coma 
ends  the  disease,  should  an  effusion  of  blood  take  place,  and  this  is  a  com- 
mon terroination. 

The  pulse  during  the  first  two  or  three  days  varies  from  60  to  70,  while 
towards  the  end  it  becomes  much  more  frequent  and  very  full.  Daring 
the  invasion,  and  after  the  disease  is  fully  established,  especially  if  the 
inflammation  extends  to  the  base,  the  head  may  be  drawn  backwards  and 
downwards. 

RamskilP  has  called  attention  to  the  hyper-sensitiveness  of  the  cornea, 
and  I  have  been  often  impressed  by  another  symptom,  viz.,  the  redness  of 
the  conjunctiva  and  the  constant  tendency  to  lachrymation.     Vomiting 
very  commonly  takes  place,  and  is  always  quite  a  suggestive  symptom  of 
meningeal  trouble.    When  the  disease  follows  otitis  its  onset  is  not  so  sud- 
den as  when  it  is  the  result  of  injury,  but  a  train  of  symptoms  of  gradual 
appearance  marks  the  extension  of  the  morbid  process  step  by  step, 
though  iu  some  instances  rigor  with  sudden  coma  may  be  the  first  indica- 
tion of  mischief.     This  is  in  most  cases  the  purulent  form.     Cases  of  the 
idiopathic  variety  of  pachymeningitis  are  quite  rare,  although  several  have 
been  reported  by  Abercrombie  and  other  older  writers.    One  case  related 
b\^  the  former  authority  may  be  worth  mentioning.   This  writer  also  gives 
six  others  which  originated  from  middle  ear  disease  or  abscesses  in  other 
bony  cavities.     These  latter  cases  are  not  uncommon,  if  we  may  accept 
the  experience  of  aurists  and  surgeons.    Abercrombie's  ^  patient,  in  whom 
the  disease  was  idiopathic,  died  in  fifteen  days.     The  first  indication  was 
severe  pain  in  the  left,  temple,  which  continued  for  two  weeks,  when  a 
"swelling"  appeared  beneath  the  left  upper  eyelid.   Four  days  before  her 
death  violent  convulsions  took  place,  which  were  preceded   by  slight 
rigors.     The  swelling  was  punctured,  and  a  considerable  quantity  of  pus 
escaped.   A  probe  passed  into  the  opening  came  in  contact  with  bone,  and 
could  be  inserted  for  some  distance,  the  end  being  in  contact  with  the  roof  of 
the  orbit.   During  previous  days  her  condition  had  varied  to  a  great  degree, 
and  at  times  she  seemed  to  be  very  comfortable.     On  the  day  before  her 
death  she  complained  of  vertical  headache,  became  semi-comatose,  and 
died  in  this  state.    Extensive  discoloration,  thickening,  and  other  changes 
in  the  dura  mater  were  found  with  adventitious  membrane  and  pus.     In 
a  case  detailed  to  me  by  Drs.  White  and  Asch  of  this  city,  there  was  al- 
ternating paralysis  associated  with  aural  disease  which  afiTected  the  ears  in 
turn. 

Fizeau^  mentions  a  case  which  closely  resembled  this  one,  and  another 
quoted  by  Abercrombie,  and  seen  by  Prathernon,  was  also  of  idiopathic 
origin.  Abercrombie's  other  cases  presented  common  symptoms  which'  were 
traced  to  assignable  causes.     Dr.  Clark*  has  presented  five  eases  of  the 

^  Eussell  Reynolds'  System  of  Medicine,  vol.  ii.,  page  325. 
^  Abercrombie  on  the  Brain,  page  21. 
^  Journal  de  Medicine,  torn,  ii.,  New  Series,  page  523. 
*  Transactions  New  York  Pathological  Society,  1876. 


40  DISEASES    OF    THE    CEREBRAL    MENINGES. 

acute  form,  due  to  otitis.  Dr.  Bauduy  another  Avhich  followed  scarlet 
fever,  and  many  of  the  same  kind  may  be  found  mentioned  by  other 
authorities. 

CHRONIC    rACHYMENINGITIS. 

A  far  more  interesting  class  of  cases  are  those  which  have  lasted  for 
some  time,  and  have  invaded  the  underlying  membranes,  ending  in  in- 
volvement of  the  cortex  cerebri.     The  following  is  a  fair  example : — 

Symptoms. — John  McM.,  age  30,  of  temperate  habits.  The  patient 
was  a  young  man  of  the  laboring  class,  and  was  employed  in  a  machine- 
shop  at  the  time  of  the  accident.  Three  years  ago,  while  turning  a  piece 
of  metal,  it  caught  upon  the  end  of  his  turning  tool  and  flew  out  of  the 
lathe  (which  was  driven  by  steam-power),  striking  his  head,  and  cutting  a 
scalp  wound  over  the  upper  part  of  the  right  parietal  bone.  He  fell  un- 
conscious, and  was  carried  to  his  home,  remaining  in  the  same  state  for 
about  eight  hours.  After  this  he  recovered  slowly,  was  delirious,  and  evi- 
dently had  had  convulsions.  From  this  period  to  the  time  when  I  saw  him 
his  history  was  not  very  clear,  but  he  had  had  convulsive  paroxysms  from 
time  to  time,  and  severe  headache,  which  he  complained  of  when  he  came 
for  advice.  This  pain  was  limited  to  the  right  side  of  the  head,  and  prin- 
cipally centered  at  the  injured  spot.  His  face  was  quite  puffed  and 
swollen,  and  his  eyes  were  red  and  watery.  Pressure  upon  the  cicatrix 
caused  intense  pain.  His  right  pupil  was  slightly  enlarged,  and  he  com- 
plained that  his  vision  was  imperfect.  Sleep  was  disturbed  by  the  pain 
which  would  often  occur  in  paroxysms  of  a  very  intense  character.  He 
complained  that  his  left  arm  felt  stiff,  and  that  his  fingers  were  cold,  but 
I  was  unable  to  find  any  loss  of  power.  He  continued  in  this  state  for  a 
year  or  more,  and  when  I  next  saw  him  his  speech  had  become  slow  and 
hesitating,  and  his  face  wore  rather  a  silly  expression.  He  then  com- 
plained of  some  feebleness  of  the  left  arm  and  leg.  The  headache  had  not 
abated,  and  the  convulsions  had  been  much  more  frequent.  His  friend 
who  came  with  him  stated  that  his  mind  had  greatly  changed,  that  his  be- 
havior was  eccentric,  and  that  he  had  had  delusions  of  various  kinds.  I 
subsequently  lost  sight  of  him.  In  some  features  this  case  resembles  one 
of  softening.  This  form  of  chronic  pachymeningitis  is  much  more  obscure 
when  it  is  connected  with  syphilis.  There  is  not  only  a  great  /dispropor- 
tion between  the  severity  of  the  symptoms  and  the  extent  of  the  morbid 
process,  but  symptoms  of  great  variety  may  be  evinced  as  expressions  of 
pachymeningitis  of  syphilitic  origin.^  Lagneau  fils^  reports  a  case  in  which 
the  only  symptom  was  headache,  which  was  most  violent  at  night.  Post- 
mortem examination  revealed  pachymeningitis  over  the  anterior  lobes  of 
the  cerebrum,  with  bony  plates  and  some  sclerosis  of  the  brain -substance. 
There  was,  in  addition,  extensive  perforation  of  the  ethmoid  bone.  In- 
stances are  related  by  Gama  where  the  patients  had  ditd  conscious, 

1  Trans.  N.  Y.  Path.  Soc,  vol.  i.,  p.  13. 

2  Observation  3,  Lagneau,  Maladies  syphilitiques  du  Sysleme  nerveux.     Paris, 
1860. 


CHRONIC    PACHYMENINGITIS.  41 

and  their  meninges  were  found  to  be  decidedly  affected.  Keyes/  in  a 
most  complete  and  exhaustive  memoir,  presents  a  number  of  cases  of 
hemiplegia  which  were  the  ultimate  result  of  the  meningeal  inflamma- 
tion, and  calls  attention  to  the  pain  which  precedes  the  hemiplegia,  and 
which  is  always  produced  when  pressure  is  made  upon  the  cranium.  A 
feature  of  the  hemiplegia  is  the  absence  of  any  loss  of  consciousness. 

Syphilitic  meningitis  of  this  description  is  very  often — I  may  say  almost 
always — symptomatized  by  a  decided  failure  in  the  mental  powers,  which 
begins  in  fact  as  soon  as  the  pathological  process  manifests  itself  by  any 
symptoms  at  all.  I  regard  this  slowness  of  intellectual  action  which,  by 
the  Avay  is  general,  as  almost  pathognomonic.  In  some  cases  it  has  been 
almost  the  only  symptom  of  a  pachymeningitis  which  was  not  recognized 
until  after  death.  I  have,  since  the  appearance  of  the  first  edition  of 
this  book,  been  called  to  see  several  persons,  who  have  subsequently  died, 
presenting  an  imperfect  hemiplegia — that  is  to  say,  a  hemiplegia  of  a 
comparatively  light  character,  but  associated  with  an  equally  light  coma, 
lasting  several  days.  There  was  not  even  laborious  breathing,  and  it  was 
possible  to  rouse  the  patients.  It  strikes  me  that  in  such  cases  the  pres- 
sure had  been  quite  gradually  developed,  and  the  cerebral  mass  had  be- 
come to  a  degree  accustomed  to  the  pressure  of  the  new  deposit.  ''Bum- 
stead  and  Taylor  thus  describe  the  later  stages  of  syphilitic  meningitis  : 
"A  general  adynamic  condition  sometimes  supervenes  in  patients  affected 
with  chi'onic  inflammation  of  the  meninges,  which  either  ends  fatally  or 
renders  them  hopelessly  bedridden.  This  weakness  may  be  due  to  mere 
lack  of  innervation,  or  may  be  complicated  by  mild  ataxic  phenomena, 
characterized  by  unsteady  gait  and  uncertain  movements.  The  dullness 
of  intellect  by  day  is  succeeded  by  nocturnal  delirium.  When  lying  in 
bed  such  a  patient  resembles  one  in  typhoid  fever,  but  there  are  marked 
points  of  difference.  He  is  sleepy  and  dull,  and  his  face  is  utterly  expres- 
sionless. The  tip  and  edges  of  his  tongue  are  red,  but  the  organ  is  never, 
unless  late  in  fatal  cases,  dry,  cracked  and  covered  with  sordes.  Anorexia 
and  constipation  are  often  quite  marked.  The  pulse  ranges  from  80  to 
110,  is  full  and  not  wiry.  The  temperature  may  be  elevated  in  the  morn- 
ing to  100°  F.,  and  at  night  to  103°  or  104°  F.  If  conscious,  the  patient 
complains  of  intense  headache  and  weariness.  In  a  week  or  ten  days  he 
passes  into  a  condition  of  complete  unconsciousness,  perhaps  broken  by 
brief  lucid  intervals.  The  urine  and  feces  are  passed  involuntarily.  If 
not  relieved,  the  condition  soon  becomes  more  serious;  the  temperature 
continues  to  rise,  and  the  pulse  increases  in  rapidity;  no  food  is  taken,  and 
the  stupor  merges  into  fatal  coma."  The  above  account  is  a  most  graphic 
one,  and  is  a  striking  picture  of  a  common  form  of  trouble. 

Fournier  is  inclined  to  fix  the  time  for  the  development  of  syphilitic 


^  Syphilis  of  the  Nervous  System.     New  York,  1870. 

2  The  Pathology  and  Treatment  of  Venereal  Diseases  by  Bumstead  and  Taylor, 
4th  edition,  p.  655. 


42  DISEASES    OF    THE    CEREBRAL    MENINGES. 

meoingcal  symptoms  much  later  than  those  authors  who  have  met  with 
these  symptoms  in  quite  recent  cases. 

Of  my  own  cases  I  have  never  seen  syphilitic  pachymeningitis  before  the 
end  of  the  third  year,  and  in  most  instances  at  least  six  or  eight  years  after 
primary  infection.  In  the  case  seen  with  Dr.  Asch  the  development  of 
symptoms  followed  at  least  fifteen  years  after  the  primary  disease.  It  is 
probable,  however,  that  there  are  cases  of  acute  trouble  with  early  de- 
velopment of  active  meningeal  inflaramation. 

A  form  of  syphilitic  pachymeningitis  may  follow^  external  syphilitic  dis- 
ease of  the  cranial  bones.  I  may  illustrate  the  features  of  such  an  attack 
by  the  following  case,  reported  by  Dr.  Jas.  R.  Wood : — 

Marie  C,  aged  20,  was  admitted  to  Bellevue  Hospital,  on  account 
of  an  eruption  of  two  weeks'  duration,  which  had  steadily  progressed 
from  a  few  points  until  it  had  become  general,  being  most  profuse  on  the 
face,  neck,  arms,  and  scalp. 

The  eruption  presented  a  distinct  co])pery  hue,  and  was  of  two  varietie-!. 
There  were  three  rupitic  phlegina  on  the  head,  each  of  whicli  contained  a 
little  pus,  and  three  or  four  on  the  shoulders  and  back  of  the  same  cha- 
racter.    The  rest  wei-e  tubercular. 

She  stated  that,  though  often  exposed,  she  had  never  suffered  from  pri- 
mary syphilis,  but  that  there  was  a  sore  on  her  thigh,  near  the  vulva, 
which  appeared  two  weeks  before  the  eruption. 

On  examination,  a  simple  chancre  was  found  at  the  point  complained 
of;  there  was  also  a  chancre  of  limited  extent  in  the  vagina.  Soon  after 
admission  she  was  observed  to  have  a  shuffling  gait,  and  when  questioned 
ab  )Ut  it  stated  that  her  right  arm  and  leg  "  seemed  to  be  getting  weak." 
The  treatment  consisted  in  the  use  of  the  corrosive  chloride  of  mercury  in 
Huxham's  tincture  of  bark,  combined  with  generous  diet. 

The  eruption  on  the  scalp  was  left  undisturbed.  The  quantity  of  pus 
contained  in  each  point  was  quite  small,  and  it  was  deemed  best  to  let 
them  alone.  One  of  them  situated  over  the  parietal  bone  of  the  left  side 
was  something  larger  than  its  fellows ;  none  of  them,  however,  increased 
in  size  materially. 

There  was  very  little  improvement  in  the  eruption,  but  the  hemiplegia 
steadily  increased. 

Her  appetite  became  poor,  she  began  to  have  vomiting,  and  exhibited 
a  cachectic  appearance.  The  bichloride  was  necessarily  discontinued,  and 
mercurial  vaporization  substituted. 

The  hemiplegia  became  more  complete,  and  her  mind  began  to  be  ob- 
scured. The  stupidity  gradually  deepened  into  profound  coma,  in  which 
condition  she  died  on  the  30th. 

Autopsy. — There  was  a  denudation  of  the  parietal  bone  of  the  left  side 
of  the  periosteum,  at  a  jjoiut  corresponding  with  the  rupitic  spot  above 
spoken  of. 

On  removing  the  calvarium,  the  dura  mater  was  found  inflamed  and 
firmly  adherent  to  the  skull,  just  beneath  the  denuded  spot  on  the  parietal 
bone  and  the  eruption. 

A  small  opening  was  found  communicating  between  them,  perforating 
the  cranial  walls,  and  looking  very  much  like  a  worm-hole. 

The  brain  at  a  point  correspondiug  with  the  inflamed  dura  mater  pre- 
sented a  greenish  appearance. 


CHRONIC  PACHYMENINGITIS. 


43 


There  was  also  an  evident  fulness  and  fluctuation.  On  making  an  in- 
cision an  abscess  was  discovered  which  contained  about  ^iij  of  pus.  The 
other  organs  were  healthy. 

As  a  result  of  continued  congestion  we  may  have  a  form  of  pachy- 
meningitis such  as  follows  chronic  mania,  I  have  seen  this  change  repeat- 
edly as  a  secondary  condition,  but  it  must  be  confessed  that  the  other 
meninges  were  as  well  affected. 

Causes. — They  may  be  briefly  enumerated  as  external  injury,  otitis, 
syphilis,  alcoholism,  and  various  acute  diseases,  among  them  rheumatism. 

Morbid  Anatomy  and  Pathology. — In  the  majority  of  cases 
the  inflammation  is  transmitted  to  one  or  more  of  the  important  sinuses. 
The  most  favorable  points  for  the  extension  of  disease  of  the  temporal 
bone  are  the  narrow  space  between  the  mastoid  cells  of  this  bone  and  the 
transverse  sinus,  and  that  between  the  cavity  of  the  tympanum  and  the 
jugular  fossa;  and  the  proximity  of  the  auditory  meatus  to  the  petrosal 
sinus,  and  the  different  canals  which  contain  the  nerves,  to  adjacent  intra- 
cranial parts.  The  bony  walls  between  these  locations  are  of  a  perforated 
and  lamellar  character,  and  when  attacked  by  caries  are  very  apt  to  be 
destroyed. 

Fig.  11. 


Osteoma  of  Dura  Mater  (Laneereaux). — a.  Bony  Plate,    h.  Perforation. 
Mater,     e.  Parietal  Bone.     /.  Scalp. 


c.  Falx.     d-   Dura 


If  the  disease  be  of  a  syphilitic  nature  there  is  generally  a  gummatous 
deposit  scattered  through  the  tissues,  and  the  under  surface  of  the  dura 
mater  is  often  covered  by  a  syphilitic  exudation  which  can  rarely  be 
mistaken.  If  it  be  the  result  of  a  traumatism,  the  membrane  is  seen  to 
be  thickened,  opalescent,  and  congested.  In  old  cases  it  is  found  to  be 
closely  adherent  to  the  cranial  bones,  or  it  may  contain  long  plates. 

In  this  form  of  inflammation  the  morbid  changes  may  be  seen  best  at 
the  convexity. 


44  DISEASES   OF   THE   CEREBRAL   MENINGES. 

Prognosis. — The  outlook  is  invariably  bad,  for  in  one  variety  the 
patient  is  carried  off  in  a  few  days,  or,  should  the  disease  become  chronic, 
its  progressive  nature  must  lead  us  to  expect  an  ultimate  implication  of 
other  parts,  and  cortical  softening  or  sclerosis  and  atrophy  are  probable 
terminations. 

Treatment. — Treatment  should  be  directed  in  the  beginning  to  the 
cause,  and  if  there  be  otitis,  a  free  escape  of  pus  should  be  provided  for, 
and  counter-irritants,  topical  applications,  and  leeches  should  be  em- 
ployed. If  the  pachymeningitis  be  attended  by  much  pain,  cold  to  the 
head  and  free  administration  of  the  bromides  will  be  of  service.  The 
leeches  may  be  applied  to  the  tragus  of  the  ear,  or  to  the  mucous  mem- 
brane of  the  nostril. 

CHRONIC   PACHYMENINGITIS   WITH    HJEMATOMA. 

It  has  been  the  custom,  among  certain  writers  lately,  to  speak  of  htema- 
toma  as  an  inevitable  result  of  pachymeningitis.  This,  I  think,  is  a  mis- 
take, for  the  production  of  blood-cysts  is  not  the  invariable  rule.  If,  how- 
ever, the  thickening  of  the  dura  mater  is  excessive,  there  may  be  a  gradual 
destructive  process,  which  will  be  described  when  we  come  to  speak  of  the 
morbid  anatomy  and  pathology  of  the  affection. 

The  disease  may  begin  as  I  have  already  described,  and  may  advance 
to  a  certain  point  before  the  grave  symptoms  which  indicate  rupture  and 
consequent  meningeal  hemorrhage  are  expressed.  These  may  vary  in  in- 
tensity in  proportion  to  the  extent  of  the  effusion,  which  may  be  even  so 
great  as  to  produce  sudden  death,  but  sucii  an  early  result  is  exceptional. 
The  course  of  the  disease  is  generally  more  gradual,  and  there  is  at  first 
an  initial  hemorrhage  of  slight  extent,  which  is  followed  in  a  great  num- 
ber of  cases  by  two  or  three  others.  In  some  respects  this  effusion  resem- 
bles cerebral  hemorrhage  in  the  production  of  acute  symptoms,  but  they 
are  nearly  always  less  profound;  and  it  is  not  so  frequently  followed  by 
complete  paralysis. 

Symptoms. — The  early  symptoms  of  pachymeningitis  that  I  have 
enumerated  are  those  preceding  the  immediate  evidences  of  the  effusion. 
They  may  be  reinforced  by  loss  of  memory  and  stupidity,  and  after  a  few 
months  there  may  be  a  transitory  loss  of  consciousness  and  incomplete 
hemiplegia  which  is  characterized  by  much  hypersesthesia. 

The  phenomena  of  the  attack  are  thus  described  by  Huguenin:'  "Se- 
vere headache,  just  before  the  attack;  after  loss  of  consciousness  has  oc- 
curred, contracted  pupils,  not  reacting ;  in  a  few  cases,  paralysis  of  the 
facial  nerve,  on  the  side  opposite  to  that  of  the  hsematoma;  sometimes 
hemiplegia.  These  latter  symptoms  only  occur  in  one-sided  hemorrhages. 
A  marked  change  in  the  color  of  the  face  is  another  of  the  symptoms  re- 
ported. At  the  commencement  of  the  attack,  which  is  usually  sudden, 
the  face  becomes  flushed ;  the  pulse  is  full  and  rapid,  but  soon  grows  small 

'  Ziemssen,  Cycloptedia  of  the  I'ract.  of  Med.,  translation,  vol.  xii.,  p.  409. 


CHROXIC    PACHYMENINGITIS    WITH    HEMATOMA.  45 

and  irregular,  and  pallor  succeeds  the  flushing.  In  some  cases  the  pulse 
is  slow ;  in  others  there  is  an  increase  in  rapidity,  continuing  up  to  the 
time  of  death.  Contractures  of  the  extremities,  and  slight  transitory 
twitchings,  Avere  present  in  a  few  cases." 

Instead  of  hemiplegia  there  may  be  one-sided  convulsions,  but  these 
depend  very  much  on  the  degree  of  pressure  exerted  upon  the  cortex- 
cerebri.  The  condition,  strange  to  say,  is  sometimes  arrested  after  an 
indefinite  period,  and  there  is  a  return  to  the  normal  state,  but  traumatic 
hsematoma  is  usually  fatal. 

Schuhberg^  assents  to  the  view  held  by  Herschl,  Virchow,  and  Cru- 
veilhier,  that  hsematoma  is  always  the  result  of  fibrinous  inflammation, 
and  believes  that  the  prognosis  is  grave.  In  this  paper  he  considers  the 
duration  of  a  fatal  case  to  be  about  one  month. 

Causes. — Hsematoma  is  a  disease  of  adult  life,  and  twenty-two  per 
cent,  of  the  cases  collected  by  Huguenin  were  between  the  seventieth  and 
eightieth  years,  and  Durand-Fardel  found  that  77.4  per  cent,  of  all 
cases  were  men,  and  22.6  per  cent,  were  women.  As  causes  may  be  men- 
tioned various  cachectic  and  other  diseases,  among  them  Bright's  disease, 
scurvy,  syphilis,  typhus  fever,  rheumatism,  smallpox  and  scarlatina,  al- 
coholism and  sunstroke,  or  any  condition  which  is  conducive  to  continued 
hypersemia  of  the  dura  mater. 

Morbid  Anatomy  and  Pathology, — The  process  involved  in  the 
production  of  hsematoma  is  an  exceedingly  complicated  one,  consisting  in 
the  production  of  new  vessels  and  new  layers  of  fibrine  due  to  the  extrava- 
sation of  blood.  The  first  layer  of  this  new  tissue-formation  takes  place 
in  contact  with  the  arachnoid,  and  ultimately  others  form  and  become 
organized.  The  formation  of  the  blood-cyst  is  due  to  the  rupture  of  one 
of  the  new  vessels,  and  the  extravasation  becomes  surrounded  by  a  layer 
of  tissue  which  may  be  so  firm  as  to  pi-eserve  the  cyst  contents  unchanged. 
This  is  particularly  the  case  in  t,he  smaller  cysts.  The  skull  is  sometimes 
found  to  be  thin  as  seen  by  Hyrtl,^  but  this  is  not  common,  and  some 
writers,  among  them  Textor''  and  Rokitansky,*  consider  that  the  reverse 
is  to  be  seen  in  a  greater  number  of  cases.  I  may  briefly  enumerate  the 
post-mortem  appearances  as  follows  :  Beneath  the  dura  mater  may  be  found 
a  layer  of  coagulum  which  contains  fibrinous  shreds  binding  it  to  the 
membrane  itself.  If  the  case  be  of  long  duration  several  layers  of  false 
membrane  containing  bloodvessels  are  to  be  found  attached  to  the  dura, 
and  the  late  formations  may  be  distinguished  from  those  of  early  origin. 
Between  these  layers  it  is  not  unusual  to  find  the  results  of  interstitial 
hemorrhages  which  exist  as  blood-clots  iu  different  styles  of  organization. 
The  thickening  of  the  dura  mater  is  thus  described  by  Fox  :  "  In  the 
non-purulent  form  of  the  new  formation,  the  result  of  inflammation  be- 


Schmidt's  Jahresbericht,  vol.  104,  pp.  164,  165. 
Ziemssen's  Encycl.,  vol.  xii.  Am.  Tran.,  Art.  "  Meningitis." 
Wiirzburg  Verliandlung,  vii.  1857. 
Eokitansky,  quoted  by  Huguenin. 


46  DISEASES   OF    THE    CEREBRAL    MENINGES. 

comes  very  quickly  the  seat  of  vessels  aud  is  composed  of  several  layers ; 
those  nearest  the  dura  mater  being  composed  of  compact  lustrous  connee 
tive  tissue  fibres  almost  as  dense  as  the  dura  mater  itself,  whilst  the  layer 
further  removed  from  the  dura  mater  is  rich  in  cells  with  small  narrow 
vessels,  aud  the  layer  nearest  the  arachnoid,  often  firmly  uniting 
the  arachnoid  to  the  dura  mater,  is  remarkable  for  very  large  capilla- 
ries." 

The  size  of  the  hematoma  may  vary  from  that  of  a  small  beau  to  that 
of  an  orange,  and  in  one  case,  the  autopsy  of  which  was  made  by  Dr. 
Huber  of  the  Colored  Home,  the  blood-cyst  covered  one  entire  side  of 
the  brain,  and  was  fully  an  inch  in  depth.  The  patient  was  under  the 
care  of  Dr.  Whitall,  who  kindly  contributes  the  following  notes : — 

P.  B.,  60,  widower,  N.  Y.  ;  mulatto  ;  father,  mother,  and  one  brother 
died  of  phthisis.  The  patient  has  been  intemperate,  but  now  drinks  only 
in  moderation.  He  denies  venereal  disease  ;  twenty-five  years  ago  he  had 
smallpox,  and  has  since  had  intermittent  fever  aud  cholera.  His  trouble 
dated  from  an  injury  seven  years  ago.  He  was  thrown  from  a  hay-truck 
to  the  ground,  falling  upon  his  head,  and  causing  blood  to  flow  from  his 
left  ear ;  but  he  was  able  to  walk  to  his  home,  one  mile  distant.  He 
seems  to  have  received  no  very  serious  injury,  if  we  may  judge  from  the 
immediate  symptoms.  Since  the  fall  he  has  been  troubled  with  headache 
off  and  on,  increased  by  apjjroaching  a  fire.  He  cannot  appreciate  the 
ticking  of  a  watch  pressed  to  his  left  ear.  About  a  fortuight  ago  he  had 
a  chill,  fever,  and  cough,  some  pain  in  back,  with  soreness  around  the 
whole  gluteal  region.  Urination  was  slow,  disturbed,  and  at  one  time  he 
was  unable  to  pass  water  ;  at  another  it  would  be  too  free  ;  has  been 
growing  weaker  since. 

June  15,  1874.  On  admission  patient  was  confined  to  bed  ;  owing  to 
apparent  weakness  in  lumbar  region  he  was  unable  to  stand.  In  a  few 
days  he  began  to  improve  under  the  administration  of  iodide  of  potash. 
AValks  with  a  staggering  gait,  and  cannot  follow  a  straight  line.  On 
closure  of  eyes  does  not  have  a  tendency  to  fall.  Heavy  expression  of 
countenance.  No  diminution  in  acuteness  of  sensibility  can  be  discov- 
ered over  any  portion  of  the  body.  Had  incontinence  of  urine  on  ad- 
mission ;  is  not  so  troubled  at  present  time.  Can  walk  about  the  ward  ; 
at  times  can  dress  without  assistance.  To-day  complains  of  frontal  head- 
ache ;  sleeps  very  soundly,  with  stertorous  breathing.  Appetite  good ; 
bowels  constipated. 

2Uli.  Staggering  gait,  and  inability  to  walk  in  a  straight  line,  still 
present.  If  he  closes  his  eyes  while  standing,  there  is  a  tendency  (which 
by  an  effort  he  can  overcome)  to  fall  backward.  Complains  of  pain  on 
right  side  of  head  and  face  ;  sleeps  most  of  the  day  in  a  chair ;  at  night 
snores  loudly.  Bowels  constipated.  Nocturnal  incontinence  of  urine 
exists. 

Feb.  6,  1875.  To-day,  while  patient  was  sitting  in  a  chair,  he  had  a 
convulsion,  and  then  became  comatose.  Urine  albuminous.  Ordered  ol. 
tiglii  vci  iv,  after  the  action  of  which  he  appeared  much  better. 

15/^.  Very  little  change  in  patient's  general  condition  since  above  note. 
Is  still  apathetic,  and  complains  of  pain  in  the  head,  on  right  side  espe- 
cially. There  is  still  right  facial  jiaralysis,  with  somewhat  diminished 
sensibility  in  this  region.     The  tongue  deviates,  if  auy,  to  the  right.     Pu- 


CHRONIC    PACHYMENINGITIS     WITH     HiEMATOMA.  47 

pils  normal  in  size  and  reaction.  No  notable  change  in  hearing.  No 
loss  of  motion,  though  the  right  arm  and  leg  are  weaker  than  the  left. 
The  lower  limbs  (left  more  readily  than  right)  can  be  drawn  upwards, 
and  extended  with  little  trouble.  He  is  unable  to  walk  or  stand  without 
being  supported,  as  the  right  leg  gives  away  ;  complains  of  a  considerable 
pain  in  the  upper  portion  of  the  limb.  Has  occasional  involuntary  pas- 
sages of  urine  and  feces;  as  a  general  thing,  however,  the  bowels  are  con- 
fined ;  urine  evacuated  with  considerable  force. 

March  19.  Appears  to  be  losing  strength  very  raj>idly.  Will  not  an- 
swer when  spoken  to.     Temp.  991°. 

21st.     Died  about  9  P.  M  comatose. 

Autopsy  36  hours  post-mortem — Rigor  mortis  marked.  Body  slightly 
emaciated. 

The  dura  mater  was  found  very  firmly  adherent  to  the  calvarium  to 
the  right  of  the  longitudinal  sinus,  and  over  a  considerable  portion  of  the 
convexity.  After  removing  the  dura  mater,  the  pia  mater  on  the  left 
side  was  discovered  to  be  unusually  dry  and  congested,  with  here  and 
there  slight  patches  of  lymph.  Ihe  convolutions  throughout  this  hemi- 
sphere were  greatly  flattened,  and  the  sulci  nearly  obliterated.  In  the 
right  cranial  cavity  a  large  hoematoma  existed.  The  tumor  pear-shaped, 
with  a  larger  extremity  anteriorly,  extended  from  the  anterior  portion  of 
the  second  frontal  convolution  to  the  posterior  portion  of  the  second  tem- 
poral, and  from  within  an  inch  of  longitudinal  fissure  to  junction  of 
lateral  portion  with  base  of  skull. 

The  right  hemisphere  was  correspondingly  compressed  downwards, 
backwards,  and  to  the  left.  The  depression  corresponded  to  the  shape  of 
the  tumor  and  was  so  situated  that  the  greatest  amount  of  pressure  came 
uj)on  the  left  lateral  ventricle.  The  dimensions  of  this  growth  were  as 
follows:  6}  inches  antero-posteriorly ;  4  inches  vertically  in  greatest 
diameter  ;  and  about  two  inches  in  thickness. 

In  addition  to  the  htematoma,  a  serous  cyst  (about  the  size  of  a  hickory- 
nut),  evidently  originating  from  an  old  hemorrhage  in  the  subjacent 
brain  structure,  the  cicatrice  of  which  still  remains,  was  seen  beneath  the 
anterior  lobe.  Back  of  this  another  cyst,  the  walls  of  which  were  chiefly 
composed  of  softened  brain  tissue,  was  discovered,  which,  upon  closer 
investigation,  was  ascertained  to  be  continuous  with  the  right  lateral  ven- 
tricle through  the  middle  cornua.  The  right  ventricle  was  greatly  dis- 
tended by  serum,  while  comparatively  little  could  be  detected  in  the 
left. 

In  the  left  ophthalmic  artery  a  long,  slender  clot,  partly  dark  and 
pai'tly  translucent  and  yellowish,  existed.  No  thrombi  were  noticed  in 
the  slight  atheromatous  arteries  at  the  base  of  the  brain. 

No  c.innection  existed  between  the  pia  mater  and  the  hsematoma; 
the  relations  between  it  and  the  dura  mater  were  so  intimate  as  to  require 
dissection  before  a  separation  was  possible. 

The  petrous  portion  of  the  right  temporal  bone  was  considerably  larger 
than  the  left,  and,  upon  section,  proved  to  be  much  more  porous.  No 
other  abnormalities  were  present ;  no  evidence  of  fracture  at  the  base. 

The  way  in  which  the  tumor,  though  situated  on  the  right  side  of  the 
brain,  pressed  upon  the  left  ventricle,  explained  the  symptoms  which, 
during  life  pointed  to  an  involvement  of  the  left  side  ;  and  also  ofiei*ed  an 
explanation  as  to  the  manner  in  which  the  fluid  was  forced  through  the 
middle  cornua  of  the  right  ventricle. 


48  DISEASES    OF    THE     CEEEBRAL     MENINGES. 

Heart. — Very  flabby;  cavities  dilated,  and  filled  with  dark  coagula. 
Aortic  valves  were  slightly  thickeucd,  and  the  artery  was  atheromatous. 
Mitral  valves  thickened. 

Lnngs. — The  right  was  firmly  bound  to  chest;  very  soft  and  congested. 
The  surface  was  studded  with  pigment. 

The  left  had  also  become  adherent  to  parietes,  and,  at  the  apex,  a  few 
softened,  cheesy  points  were  discovered. 

Spleen. — Enlarged  and  congested. 

Xu-er.— Normal. 

Kidney. — Cortex  somewhat  thicker  than  usual  ;  both  organs  were 
waxy. 

Weight  of  the  organs. — Heart,  10  oz. ;  spleen,  7  oz.  ;  liver,  55  oz. ;  right 
lung,  29  oz. ;  left  lung,  18  oz. ;  right  kidney,  6  oz. ;  left  kidney,  5  oz. 

Prognosis. — The  existence  of  a  blood  tumor  of  this  kind  is  not  al- 
ways a  serious  matter.  Even  after  two  or  three  extravasations  have  oc- 
curred, a  retrogressive  course  takes  place  ;  but  this  is  rare.  Griesinger  ^ 
reports  a  case  in  which  partial  recovery  has  taken  place ;  and  in  1876  the 
patient  was  still  alive,  and  j^resented  slight  evidences  of  his  former  serious 
trouble.     This  termination  of  the  disease  is  exceptional,  however. 

Treatment. — What  has  been  said  in  regard  to  the  management  of 
uncomplicated  pachymeningitis  is  applicable  in  this  disease  ;  and,  in  addi- 
tion, venesection  has  been  advocated  by  more  than  one  authority.  It 
should  be  employed  during  the  comatose  stage  which  marks  the  occur- 
rence of  an  effusion,  and  at  the  same  time  a  drastic  cathartic  will  be 
found  to  be  of  excellent  service.  High  living  and  excessive  use  of  to- 
bacco and  alcohol  are  to  be  interdicted,  and  iodide  of  potassium  may 
be  given  with  the  idea  of  producing  absorption  of  the  new  growth. 

ACUTE  CEREBRAL    MENINGITIS. 

The  term  meningitis  has  been  applied,  clinically  speakinir,  to  that  form 
of  inflammation  which  involves  chiefly  the  arachnoid  and  pia  mater,  and 
in  its  acute  form  may  be  expressed  by  the  following  grave  and  alarming 
symptoms : — 

Symptoms. — The.se  may  be  divided  in  regard  to  their  appearance 
into  three  stages :  1st.  The  stage  of  excitement  or  irritation;  2d.  The 
stage  of  delirium;  3d.  The  stage  of  stupor. 

An  hypothetical  case  may  be  presented.  The  patient  complains  of  a 
slight  headache,  which  increases  toward  the  end  of  the  first  twenty-four 
hours.  It  may  not  be  attended  by  much  annoyance,  and  he  is  usually 
able  to  attend  to  his  daily  duties,  but  during  the  succeeding  six  or  eight 
hours  it  may  become  greatly  aggravated,  and  is  attended  by  rei-tlessnees, 
flushing  of  the  cheeks,  throbbing  of  the  temporal  vessels,  and  general  dis- 
comfort. After  a  few  hours  there  may  be  slight  rigors  or  a  severe  chill, 
which  is  often  mistaken  for  ague ;  and  the  rapid  elevation  of  temperature, 

1  Archiv.  der  Heilkuude,  1862, 


ACUTE    CEREBRAL    MENINGITIS.  49 

and  hard,  bounding  pulse  may  strengthen  the  suspicion.  The  headache 
continues,  and  is  still  not  confined  to  any  particular  locality,  but  is  so  in- 
tense that  the  patient  seeks  his  bed,  where  he  may  lie,  moaning,  sighing, 
or  tossing  restlessly  to  and  fro.  The  muscles  of  the  legs  may  twitch,  and 
the  least  noise,  such  as  the  creaking  of  a  door,  invariably  irritates  and 
startles  the  invalid  ;  bright  lights  distress  him,  and  he  closes  his  eyes  in- 
stinctively. He  keeps  his  hands  over  his  ears  so  that  he  may  not  hear 
noises  in  the  room,  or  firmly  presses  his  aching  temples.  There  may  be 
vomiting  which  is  not  dependent  upon  the  condition  of  the  stomach,  is  not 
attended  by  retching,  and  occurs  whether  the  stomach  be  empty  or  full. 
If  the  patient  be  a  child,  there  are  generally  convulsions  of  a  very  violent 
character.     These  constitute  the  first  stage. 

Active  delirium  usually  appears  during  the  first  two  days,  and  continues 
through  the  greater  part  of  the  second  stage.  The  patient  screams  in  an 
agonizing  manner,  and  alarms  those  who  may  be  with  him,  adding  greatly 
to  the  distressing  character  of  his  sufferings.  The  delirium  now  begins  to 
subside,  or  may  be  supplanted  by  coma.  The  temperature  becomes  lower, 
and  the  pulse  loses  much  of  its  force  and  rapidity.  The  head  is  hot,  and 
the  respiration  becomes  irregular  and  sighing.  The  bowels,  which  were 
constipated  in  the  first  stage,  still  continue  so,  and  the  tongue  is  coated 
with  a  dirty-white  fur.  There  may  be  convulsions  at  this  time,  which 
RamskilP  says  may  precipitately  throw  the  patient  into  the  third  stage, 
which  is  one  of  collapse.  This  stage  may  resemble  that  of  advanced  ty- 
phoid. Sordes  on  the  teeth,  pinched  features,  dark  circles  about  the  eyes, 
fluttering  pulse,  great  prostration,  with  loss  of  muscular  power,  dilated 
pupils,  stertorous  breathing,  and  the  unconscious  passage  of  feces  and 
urine,  are  all  forerunners  of  death.  Should  the  force  of  the  inflammation 
be  exerted  at  the  base,  the  symptoms  are  much  more  violent,  and  j)araly- 
ses  of  cranial  nerves  are  not  uncommon. 

Causes. — In  considering  the  predisposing  causes  of  acute  meningitis 
it  will  be  well  to  inquire  what  are  the  influences  of  sex  and  age.  The  re- 
ports of  the  New  York  Board  of  Health  show  that  during  the  years  1867, 
1868,  1870,  1871, 1872,  and  1873  there  were  4321  deaths  from  meningitis 
in  the  city  of  New  York,  2506  of  whom  were  males,  and  1815  females ; 
3434  were  children  under  5  years;  of  these  1873  were  males,  and  1561 
females.  It  will  therefore  be  seen  that  males  are  more  often  affected  than 
the  other  sex,  and  that  the  large  proportion  of  cases  occur  among  chil- 
dren. 

Rilliet  and  Barthez  take  an  opposite  view  of  the  matter,  and  consider 
the  disease  to  exist  more  frequently  after  the  fifth  year.  My  own  experi- 
ence and  the  Health  Board's  statistics  lead  me  to  think  that  after  this 
period  of  early  life,  the  adult  cases  are  comprised  in  the  interval  between 
the  twentieth  and  fiftieth  years,  and  I  am  unable  to  find  the  records  of 
many  cases  after  the  sixtieth  year,  and  am  therefore  disposed  to  believe 
that  the  disease  is  rare  after  that  time.     Various  predisposing  causes  give 

^  Article  in  Reynolds'  System  of  Medicine,  p.  369,  vol.  ii. 


50  DISEASES   OF   THE   CEREBRAL   MENINGES. 

rise  to  the  affection,  and  none,  I  think,  plays  a  more  important  part  in 
the  production  of  the  adult  variety  than  continued  dram-drinking  and 
hard  work  in  warm  places.  Over-use  of  the  mental  powers,  and  various 
disorders,  such  as  syphilis  and  gout,  are  favorable  to  its  development. 

Croupous  pneumonia,  acute  rheumatism,  diphtheria,  extension  of  dis- 
ease from  the  tympanic  cavity,  blows  upon  the  head,  and  sudden  changes 
of  temperature  of  any  kind,  are  the  direct  causes  of  acute  meningitis.  la 
one  of  my  cases  the  disease  was  the  result  of  a  sea-bath.  The  patient, 
after  bathing,  sat  for  some  time  with  uncovered  head  upon  the  beach  ex- 
posed to  the  heat  of  a  noonday  sun.  Haeddeus^  reports  a  case  of  this  dis- 
ease which  resulted  from  typhoid  fever. 

Diagnosis. — Acute  cerebral  meningitis  may  be  mistaken  or  con- 
founded with  cerebritis,  typhoid  fever,  or  delirium  tremens.  The  deli- 
rium, headache,  and  disorders  of  motility  are  much  less  marked  in 
cerebritis  than  in  acute  meningitis,  and  it  must  be  remembered  that  the 
pulse  in  the  latter  disease  is  much  more  rapid  and  full,  and  the  tempera- 
ture much  higher. 

Typhoid  fever  is  symptomatized  by  elevation  of  evening  temperature, 
diarrhoea,  abdominal  tenderness  and  tympanites,  muttering  delirium,  and 
the  presence  of  petechise.  Delirium  tremens  may  be  occasionally  con- 
founded with  the  disease  under  discussion,  but  it  must  be  remembered 
that  the  history  of  alcoholism — peculiar  delusions  and  alcoholic  delirium, 
the  absence  of  headache  and  the  condition  of  the  skin,  are  all  evidences  of 
delirium  tremens,  which  are  not  to  be  mistaken. 

Pathology  and  Morbid  Anatomy. — When  the  pia  mater  and 
arachnoid  become  the  seat  of  inflammation,  we  may  roughly  group  the 
lesions  and  consequent  symptoms  into  two  classes,  one  indicative  of  basal 
trouble  and  the  other  of  vertical.  In  the  former,  cranial  nerve-trunks 
■will  be  injured  or  diseased  ;  while  in  the  latter,  the  investing  membranes 
of  the  cerebrum  will  be  the  seat  of  morbid  action,  and  the  functions  of  the 
cortex  must  be  consequently  destroyed,  so  that  the  symptoms  will  be  more 
of  a  psychical  character  than  when  the  base  is  involved. 

The  recent  investigations  and  contributed  cases  of  Landouzy,''  of  which 
104  are  presented  by  this  author,  demonstrate  the  connection  between  cer- 
tain symptoms  and  lesions  of  the  description  to  be  hereafter  mentioned, 
involving  those  portions  of  the  cortex  containing  the  centres  of  Hitzig' 
and  Fritsch.  These  prove  very  clearly  that  violence  of  the  inflammatory 
process  in  certain  places  may  be  attended  by  certain  paralyses  or  contrac- 
tions of  limbs  which  are  innervated  from  these  centres.  A  case  which 
recently  came  under  my  obsei'vation  is  one  of  this  kind,  and  possesses 
great  pathological  interest. 

E.  B.,  aged  thirty-six,  born  in  Ireland,  by  occupation  a  blacksmith,  is 
a  stout,  well-made  man  of  nervous  temperament,  and  up  to  the  commence- 

'  Berliner  Klin.  Woch.  1869,  p.  564. 

^  Contribution  k  I'^tude  des  Convulsions  et  Paralyses  lides  aux  Meningo-encephalitis 
fronto-pari^tales.     Paris,  1876. 
'  Eeichert  and  Du  Bois  Reymond's  Archives,  1870,  Heft  3. 


I 


ACUTE   CEREBRAL   MENIKGITIS.  51 

ment  of  his  present  trouble  had  enjoyed  uninterrupted  good  health.  He 
has  not  had  syphilis,  and  his  habits  have  been  good.  His  mother  and 
father  are  dead,  the  former  having  died  of  old  age  and  the  latter  of  phthi- 
sis. There  is  no  family  history  of  insanity,  epilepsy,  paralysis,  nor  of  any 
organic  nervous  trouble  whatever.  Ten  years  ago,  while  working  upon  a 
fire-escape,  he  fell  to  the  ground,  two  stories  below,  striking  upon  his  head 
and  shoulder.  He  was  taken  up  unconscious,  and  remained  so  for  four- 
teen hours.  The  only  injuries  he  received  were  two  severe  scalp-wounds, 
one  of  which,  from  its  slowness  in  healing,  must  have  been  attended  by 
some  bone  injury,  for  he  was  unable  to  resume  work  until  three  months 
later.  He  says  that  purulent  accumulations  took  place,  and  that  "  the 
doctor  lanced  them."  Two  cicatrices  are  now  visible,  one  of  which  is 
about  an  inch  and  a  half  long,  and  is  situated  on  the  left  side  of  the  head 
and  covers  a  depression  about  three-quarters  of  an  inch  in  diameter  and 
one-quarter  of  an  inch  in  depth,  the  centre  of  which  is  about  one  and  one- 
half  inches  below  the  median  line,  five  inches  above  the  left  ear,  and  four 
and  three-quarters  inches  above  the  centre  of  the  left  supra-orbital  arch. 
This  is  the  only  depression  visible,  and  the  injury  on  the  right  side  was 
apparently  very  superficial. 

He  gives  no  history  of  serious  head  symptoms,  and  when  he  resumed 
work  was  in  good  condition,  there  being  no  paralysis.  About  three  months 
later  he  noticed  a  tremulousness  of  the  fingers  of  the  right  hand  and 
afterwards  of  the  arm  of  the  same  side.  There  was  no  pain  nor  loss  of 
power,  but  simply  a  marked  tremor  whenever  he  attempted  to  do  any- 
thing. This  difiiculty  increased  to  such  an  extent  that  he  was  obliged  to 
resign  his  position  as  first-class  workman,  and  become  a  helper,  using  his 
other  arm  to  work  the  bellows.  About  six  months  after  this  the  tremor 
affected  the  right  leg,  and  he  was  obliged  to  leave  his  work. 

Present  Condition  — The  patient  does  not  complain  of  head  symptoms, 
except  a  slight  hypersesthesia  of  the  right  side  of  the  face,  of  short  dura- 
tion. Vision  normal ;  fundus  of  either  eye  presents  no  abnormal  appear- 
ances ;  pupils  respond  well  to  light,  and  are  of  equal  size.  Hearing 
unaffected.  No  tremor  of  face  or  tongue,  speech  unembarrassed,  mem- 
ory good,  and  no  intellectual  trouble  whatever.  He  has  never  had  head- 
ache. 

Upper  Extremities. — Left  side  unafiected.  The  right  hand  and  arm 
are  perfectly  quiet  during  inaction,  but  when  the  most  simple  voluntary 
act  is  attempted  they  become  agitated  by  a  fine  rhythmical  tremor,  which 
becomes  more  marked  as  the  accomplishment  of  the  act  requires  greater 
nicety  of  coordination.  When  he  is  asked  to  carry  a  glass  of  water  to  his 
mouth,  he  spasmodically  grasps  the  vessel  and  carries  it  upward,  the  elbow 
being  raised,  the  tremor  meanwhile  increasing  until  the  mouth  is  reached, 
when  the  movements  become  so  violent  that  he  is  unable  to  place  the  rim 
of  the  glass  between  his  lips.  Certain  motions  are  almost  entirely  unat- 
tended by  tremor.  He  can  extend  the  arm  and  hand,  or  can  hold  them 
rigidly  upright,  and  is  able  to  pronate  the  hand,  but  movements  of  flexion 
are  attended  by  increased  violence  of  the  tremor.     Tactile  sensation  is 


52  DISEASES   OF   THE   CEREBRAL   MENINGES. 

somewhat  impaired,  but  susceptibility  to  painful  impressions  is  not  dimin- 
ished. There  is  absolutely  no  loss  of  muscular  power,  no  atrophy  of  the 
hand  or  arm,  the  thenar  eminences  being  covered  by  firm  cushions,  and 
the  interosseous  spaces  being  well  filled. 

Loiver  Extremities. — The  left  leg,  like  the  arm,  is  in  no  way  affected. 
The  right  leg,  however,  is  agitated  by  muscular  tremor  when  he  attempts 
to  use  it,  or  approximates  it  with  its  fellow,  as  in  standing  erect.  There  is 
110  loss  of  muscular  power,  but  some  anaesthesia,  the  patient  being  unable 
at  any  place  to  distinguish  two  points  of  the  ^esthesiometer,  unless  they  are 
separated  at  least  eight  centimetres. 

When  he  stands  with  his  eyes  closed  he  is  "groggy,"  but  does  not  fall. 
He  can  stand  upon  the  right  foot  alone,  but  not  upon  the  left.  When  he 
walks,  the  right  heel  is  brought  down  first,  so  that  the  heel  of  the  shoe  is 
much  worn.  He  has  some  plantar  formication  and  coldness  of  the  foot. 
He  has  suffered  from  pains  of  a  pseudo-neuralgic  nature  in  the  right 
shoulder  and  right  thigh,  which  were  centrifugal,  as  well  as  some  pains 
which  darted  from  the  heel  up  the  inner  side  of  the  leg.  The  pains  in  the 
upper  extremity  are  not  so  frequent  as  they  were  a  year  ago.  There  has 
been  no  history  of  body-constricting  baud,  pain  in  the  back,  or  vesi- 
cal trouble  of  any  description,  but  for  the  past  five  years  he  has  been 
constipated  and  obliged  to  take  purgatives.  There  are  no  contractions 
whatever. 

The  peculiarities  of  this  case  seem  to  be  the  unilateral  tremor  (not 
disorderly  movements)  excited  by  voluntary  exertion,  its  predominance 
in  flexion,  while  certain  movements  of  extension  are  almost  unattended 
by  any  embarrassment,  the  absence  of  muscular  weakness,  contractions, 
or  atrophy,  and  the  evident  dependence  of  the  trouble  upon  a  localized 
cerebral  injury  of  the  opposite  side,  which  probably  resulted  from  the 
fall. 

I  am  unable  to  arrive  at  any  conclusion  which  would  lead  me  to  consi- 
der the  symptoms  due  to  cerebro-spinal  sclerosis,  or  one-sided  posterior 
spinal  sclerosis,  if  the  latter  anomalous  condition  could  exist.  The  utter 
absence  of  loss  of  power  and  permanent  contraction  of  the  affected  limbs, 
and  the  non-extension  of  the  affection  to  those  of  the  other  side  of  the 
body  within  ten  years,  are  sufficient  to  invalidate  such  a  diagnosis. 

The  non-occurrence  of  convulsions  and  other  symptoms  of  cerebral 
tumor  renders  this  as  a  cause  of  the  tremor  quite  improbable. 

Of  course  the  assumption  that  this  patient's  symptoms  are  due  to  some 
irritative  meningeal  or  cortical  lesion  must  be  based  upon  purely  theoreti- 
cal grounds,  but  the  features  of  the  case  convince  me  that  such  a  _'condi- 
tion  of  affairs  is  by  no  means  improbable.  If  we  refer  to  the  charts  of 
Hitzig  and  Ferrier,  we  shall  find  that  they  have  located  a  cortical  region 
which  is  "  situated  on  the  ascending  frontal,  just  behind  the  upper  end  of 
the  posterior  extremity  of  the  middle  frontal  convolution,"  which  "  is  the 
centre  for  the  movements  of  the  hand  and  forearm  in  which  the  biceps 
is  particularly  engaged,  namely,  supination  of  the  hand  and  flexion  of  the 


ACUTE    CEREBPvAL    MENINGITIS,  53 

forearjn."  ^  Again,  if  we  consult  the  admirable  article  of  Turner/  we 
shall  find  very  useful  hints  which  will  enable  us  to  lay  out  the  exterior  of 
the  cranium  into  regions  corresponding  with  the  convolutions  beneath. 
One  of  these  areas,  which  has  been  called  the  upper  antero-parietal  space, 
includes  the  ascending  parietal  and  ascending  frontal  convolutions,  and 
an  injury  at  the  point  I  have  located  in  describing  this  case  would  be 
just  over  the  centre,  which,  when  experimentally  irritated,  produces 
movements  of  flexion  and  supination. 

It  is  quite  reasonable  to  suppose  that  this  irritation  occurring  with  voli- 
tional movements  is  due  to  a  natural  increase  in  the  blood  pressure  during 
mental  activity,  a  consequent  increase  in  cerebral  volume,  and  a  resulting 
meningeal  contact  with  the  depressed  portion  of  bone,  which  probably 
does  not  impinge  upon  the  cranial  contents  at  ordinary  times. 

Dr.  James  B.  Ayer  ^  reports  an  extremely  interesting  case  of  cerebral 
syphilis,  the  prominent  feature  of  which  was  the  presence  of  hallucina- 
tions of  hearing,  the  lesion  being  syphilitic  meningitis,  evinced  by  great 
pain  confined  to  the  back  part  of  the  head,  and  psychical  symptoms  of 
interest,  such  as  sluggishness  of  intellect,  unreasonable  dislikes,  and  insane 
hallucinations  of  hearing.  The  autopsy  revealed  a  significant  condition 
of  affairs,  namely,  a  patch  of  induration  of  certain  occipital  convolutions 
which  bears  out  the  statement  of  Ferrier  that  auditory  disturbance  ordi- 
narily follows  lesion  of  this  part  of  the  brain. 

"  Both  tables  of  the  skull  were  somewhat  thicker  than  usual,  at  the 
expense  of  the  diploe.  The  calvarium  was  heavy  and  dense ;  in  other 
respects  normal.  The  dura  mater  was  ordinarily  transparent.  A  recent 
coagulum  was  found  in  the  longitudinal  sinus.  There  was  nothing  special 
in  the  pia,  except  that  a  patch,  the  size  of  a  half  dollar,  over  the  upper 
occipital  convolutions  of  the  right  side  was  adherent  to  the  brain. 

"  The  middle  cerebral  artery  of  the  right  side  contained  a  small  spot 
of  chronic  endarteritis,  which  had  diminished  the  calibre  of  the  vessel 
about  one  quarter.  There  was  a  similar  patch  in  the  basilar  artery,  of 
somewhat  larger  size.  The  intitna  ran  smoothly  over  these  projections. 
On  section  they  were  found  to  consist  of  a  yellowish-white,  opaque  tissue, 
and  presented  a  marked  contrast  to  the  surrounding  healthy  tissue.  The 
convolutions  were  somewhat  flattened  ;  the  ventricles  contained  a  trifle 
more  fluid  than  normal. 

"  !N  ear  the  longitudinal  fissure,  in  the  upper  part  of  the  right  occipital 
region,  between  two  occipital  convolutions,  there  was  an  indurated  portion 
of  brain  corresponding  to  the  patch  of  meningeal  inflammation.  The 
gray  matter  was  found  atrophied  to  one  half  its  normal  thickness.  The 
neuroglia  in  the  white  substance  beneath  was  increased,  and  the  white 
substance  exhibited  a  grayish  tint,  but  nothing  else  abnormal." 

^  Functions  of  the  Brain,  page  307. 

"^  Journal  of  Anatomy  and  Physiology,  vols,  siii.,   xiv.,  November,  1873,  May, 
1874 
*  Bo3ton  Med.  and  Surg.  Journal,  Sept.  19,  1878,  page  363. 


54  DISEASES    OF    THE    CEREBRAL    MENINGES. 

In  the  majority  of  cases  the  inflammation  begins  at  the  base  and  extends 
upwards.  The  temporal  lobe  may  often  be  its  starting-point,  while  in 
other  varieties  the  meninges  covering  the  cerebellum  may  alone  be  in- 
volved. The  appearance  of  the  cranial  contents  cannot  be  mistaken,  the 
membranes  are  red,  hypersemic  and  attached  to  each  other,  and  the  arach- 
noid cavity  contains  a  considerable  quantity  of  serum.  The  fluid  in  the 
ventricles  is  increased  and  may  contain  pus,  and  the  choroid  jolexuses 
are  found  to  be  turgescent  and  enlarged.  It  may  be  stated  upon  the  au- 
thority of  Huguenin^  that  in  some  cases  the  ventricular  fluid  is 
purulent  on  one  side,  while  it  may  be  simply  serous  on  the  other.  In 
aggravated  cases  the  quantity  of  pus  may  be  considerable,  and  if  the 
meningitis  be  of  the  basilar  form  the  pia  mater  of  the  base  will  exhibit  ex- 
tensive purulent  infiltration.  The  ependyraa  of  the  ventricles  may  be 
thickened  granular,  and  contains  yellowish  deposits.  In  cases  due  to 
traumatism,  or  extension  of  other  diseases,  there  may  be  found  evidences  of 
caries  or  fracture.  The  cortex  in  nearly  every  case  of  meningitis  of  the 
convexity  is  found  to  have  undergone  decided  softening,  and  when  the 
meninges  are  removed,  some  of  the  superficial  brain-substance  is  carried 
with  them.  Microscopic  examination  will  reveal  cortical  changes  of  more 
or  less  recent  date.  The  vessel  coats  are  shrunken  or  hard,  and  areas  of 
sclerosis,  or  on  the  other  hand  breaking  down,  are  to  be  recognized. 

Prognosis. — We  should  always  hesitate  in  expressing  our  opinion  as 
to  the  course  of  the  disease,  although  so  few  cases  get  well  that  it  is  almost 
safe  to  say  that  our  patient  cannot  recover.  The  prognosis  of  syphilitic 
meningitis  is  by  no  means  hopeless.  There  may  be  a  gradual  return  to 
health  characterized  by  occasional  exacerbations  of  pain,  mental  listless- 
ness,  etc.  If  the  patient  improves  after  the  first  week,  we  may  consider 
the  prognosis  much  more  hopeful,  but  there  are  often  deceitful  lulls 
which  may  mislead  the  medical  attendant.  '^  Dr.  S.  G.  Webber  reports 
a  case  in  which  there  was  a  return  of  intelligence  just  before  death,  which, 
however,  was  temporary.  If  active  treatment  produces  beneficial  results, 
his  chances  are  better,  while  any  evidence  of  ocular  trouble,  and  conse- 
quently basal  involvement,  lessens  the  patient's  chances  materially. 
Should  the  disease  result  from  extension  or  inflammation  of  the  temporal 
bone,  the  prognosis  is  also  grave.  Death  may  occur  in  four  or  five  days, 
or  even  in  a  shorter  time,  but  the  duration  of  the  disease  may  extend  to 
the  tenth  day. 

Treatment. — Two  indications  are  to  be  met  promptly :  one  the  ab- 
straction of  blood;  the  other,  cold  to  the  head.  When  the  delirium  is 
furious,  temporal  vessels  swollen,  and  the  pulse  hard  and  bounding,  ab- 
straction of  blood  from  the  arm  is  to  be  immediately  resorted  to.  A  sug- 
gestion made  by  Holland  many  years  ago  is  one  of  value,  notwithstand- 
ing the  fact,  that  it  has  been  almost  forgotten  and  generally  disregarded,  I 
allude  to  the  application  of  leeches  to  the  hsemorrhoidal  veins ;  to  use  his 

1  Ziemssen's  Encyclopsedia,  vol.  xii.,  translation. 
=»Bost.  Med.  &  Surg.  Journal,  Vol.  ci.,  p.  361. 


RHEUMATIC    MENINGITIS.  55 

words :  "  I  know  of  no  mode  in  which  a  given  quantity  of  blood  can  be 
removed  in  equal  effect  in  cases  where  it  is  required."  ^  Cold  to  the 
scalp  either  by  ice-bags,  or  by  a  bladder  filled  with  pounded  ice,  or  an 
arrangement  of  rubber  tubes,  should  be  employed,  and  will  be  found  to 
very  speedily  relieve  the  pain.  Accepting  a  hint  from  Dr.  Chamberlain, 
of  this  city,  I  have  had  constructed,  and  have  successfully  used  an  apparatus 
such  as  I  will  describe.  It  consists  of  a  long  piece  of  rubber  tubing 
wound  upon  itself  and  securely  held  in  its  spiral  form  by  tape,  forming  a 
skull  cap.  The  upper  end  is  connected  with  an  ice-cooler  or  a  cold  water 
tap,  should  there  be  one  in  the  apartment ;  and  the  other  is  fitted  with  a 
stopcock  so  that  the  discharge  of  water  may  be  regulated.  By  this  means 
the  patient's  head  can  be  kept  cool  and  his  bed  dry  and  comfortable,  an 
impossible  state  of  affairs  where  the  douche  is  used.  Iodide  of  potassium  in 
large  doses  has  been  given  with  excellent  effect,  and  its  efficacy  in  this  dis- 
ease has  been  praised  by  Flint,  Alonzo  Clark,  and  others.  Aconite,  ergot, 
and  the  bromides  are  all  efficient  remedies  in  depressing  the  pulse  and 
quelling  the  delirium ;  and  elaterium,  saline  cathartics,  or  the  old  com- 
bination of  salts  and  senna  may  be  of  service.  Blisters  applied  behind 
the  ears  and  to  the  neck  are  excellent  adjuvants.  Should  the  patient's 
strength  be  reduced,  as  is  the  case  in  the  later  stages,  the  free  use  of 
stimulants,  nourishing  food,  such  as  milk,  egg-nog,  beef-broths,  and  nu- 
tritious but  digestible  food,  are  of  great  importance.  In  the  other  forms 
presently  to  be  alluded  to,  we  should  be  governed  by  the  existence  of 
rheumatism,  or  the  advanced  age  of  the  patient,  and  for  the  former  pre- 
scribe alkalies,  colchicum,  and  other  remedies  of  the  same  nature,  and  for 
the  latter  a  generous  diet  and  a  liberal  use  of  stimulants. 

EHEUMATIC  MENINGITIS. 

A  form  of  inflammation  of  the  meninges  may  be  connected  with,  or 
occur  during  the  course  of  acute  articular  rheumatism,  or  again  it  may 
be  found  without  any  coexisting  joint  trouble. 

Trousseau^  has  described  three  forms  of  cerebral  rheumatism.  One  of 
these  he  calls  apoplectic,  and  it  is  symptomatized  by  coma  without  paraly- 
sis ;  a  second  form,  first  described  by  Gosset,  is  that  in  which  delirium 
is  followed  by  coma ;  and  there  is  a  third  in  which  delirium  makes 
its  appearance  in  the  course  of  inflammatory  rheumatism.  Its  co-exist- 
ence with  joint-trouble  is  by  no  means  the  rule,  though  the  majority . 
of  cases  reported  have  been  of  this  character.  Posner  ^  reports  a  case  in 
which  the  inflammation  left  the  joints  and  attacked  the  meninges.  Pain 
in  the  head,  delirium,  and  slow  pulse  were  the  prominent  features  of  the 
patient's  illness,  and  recovery  took  place  in  about  two  weeks.  The  symp- 
toms of  an  ordinary  attack  of  metastatic  rheumatic  meningitis  are  these : 

^  Quoted  by  Solly.     The  Human  Brain,  etc.,  page  353. 
^Schmidt's  Jahresbericht,  vol.  113,  p.  25. 
^Encephalopathia  Rheumatica,  Ibid.,  vol.  104,  p.  167. 


56  DISEASES   OF    THE    CEREBRAL    MENINGES. 

Either  during  an  attack  of  acute  rheumatism,  or  afterwards,  the  patient 
may  become  dull  and  stupid,  and  delirium  makes  its  appearance.  This 
delirium  is  of  a  violent  character,  and  during  its  existence  the  patient 
may  have  delusions  and  hallucinations  of  sight  and  hearing.  In  a  case 
reported  by  Mesnet^  the  delusions  of  pergecution  were  a  prominent  fea- 
ture, but  there  is  no  regularity  in  this  mode  of  expression.  There  is 
usually  but  a  slight  rise  of  temperature,  though  it  may  sometimes  attain 
an  elevation  of  106°,  or  thereabouts,  and  the  pulse  at  the  same  time  be- 
comes very  rapid  and  full.  Headache  of  a  very  severe  variety,  such  as  I 
have  described  when  speaking  of  the  other  forms  of  acute  meningitis,  may 
be  present  throughout  the  illness,  and,  after  several  days,  choreiform 
movements  may  occur,  and  with  their  advent  the  delirium,  which  was 
before  inconstant,  but  now  becomes  continuous.  These  choreiform  move- 
ments are  such  as  a  nervous  embarrassed  person  would  make  in  health  when 
suddenly  disconcerted.  There  is  an  uneasy  opening  and  closing  of  the  fin- 
gers, and  the  arm  is  jerked  backwards  and  forwards.  The  patient  now 
finds  considerable  difficulty  in  swallowing,  portions  of  food  remaining  in 
the  mouth  for  some  time.  Great  prostration  and  collapse  may  supervene, 
and  he  dies  in  a  comatose  state,  or,  on  the  other  hand,  there  may  be  slow 
recovery,  the  mental  symptoms  being  the  last  to  subside. 

Vomiting  and  early  headache,  which  are  so  characteristic  of  the  other 
forms  of  meningitis,  are  absent.  Recovery  is  rare,  and  of  thirty-nine  cases 
reported  by  Vigla,^  thirty  terminated  fatally.  Should  the  patient  sur- 
vive, he  is  very  apt  to  become  insane,  the  variety  of  such  mental  trouble 
being  chronic  mania.  Huguenin^  considers  that  the  connection  of 
meningitis  with  rheumatism  is  threefold  with  respect  to  pathological 
changes : — 

"  a.  Endocarditis  is  the  connecting  link,  so  that  the  combination  is 
rheumatism,  ulcerative  endocarditis,  meningitis. 

"  b.  Purulent  inflammations  of  the  serous  membranes  form  the  con- 
necting link,  endocarditis  being  present  or  not,  as  may  be.  In  this  case, 
purulent  meningitis  is  secondary  to  purulent  inflammation  of  the  serous 
membranes  ;  this  is  very  rare,  and  the  exact  connection  is  unknown. 

"  c.  Meningitis  complicates  rheumatism  without  there  being  any  puru- 
lent deposits  in  the  body,  or  any  affection  of  heart ;  the  connection  here 
is  also  obscure." 

Da  Costa*  is  inclined  to  refer  the  brain  symptoms  in  cerebral  rheuma- 
'tism  to  two  agencies,  the  first  of  which  is  circulation  of  vitiated  blood, 
and  the  second  is  the  disturbance  of  cerebral  circulation  dependent  upon 
the  plugging  of  small  arteries  by  fine  embola,  and  he  consequently  considers 
cerebral  rheumatism  to  be  a  disease  which  is  not  essentially  an  inflamma- 
tion of  the  cerebral  meninges. 


*  Archives  Generales,  June,  1856. 

■•^  Actes  de  la  Soc.  Med.  des  H6pitaux  de  Paris,  1865,  3me  fas. 
'  Op.  cit.  p.  624. 

*  American  Journal  Med.  Sciences,  Jan.  1875. 


MENINGITIS    OF    THE    AGED.  57 

A  case  of  rheumatic  meningitis  which  recovered  under  the  use  of  cold 
baths — and  was  treated  by  M.  Fereol/  of  Paris — is  the  following: 

The  patient  was  thirty-four  years  old,  of  quiet  and  temperate  habits, 
who  was  suffering  from  acute  articular  rheumatism.  He  was  treated  at 
first  with  emetics,  sulphate  of  quinine,  and  colchicum,  but  in  five  days  he 
was  seized  with  delirium,  and  dyspnoea,  and  at  the  same  time  the 
pains  in  the  joints  disappeared.  The  temperature  of  the  body  rose  to 
forty  degrees  (Centigrade),  and  leeches,  calomel,  and  bromide  of  potas- 
sium were  given  without  success.  The  temperature  rose  further  to  forty- 
one  degrees,  and  blisters  were  placed  on  the  scalp,  and  digitalis  was 
given.  There  was  then  a  little  more  rest,  but  the  aspect  was  typhous, 
with  stupor  and  continuous  sub-delirium ;  sleeplessness,  agitation  of  the 
muscles,  subsultus  tendinum,  dry  tongue,  etc.  After  some  consultation 
with  other  physicians,  it  was  determined  to  try  the  effects  of  cold  baths 
as  the  only  remaining  resource.  This  plan  was  pursued  for  a  whole  week, 
the  patient  remaining  under  close  observation  the  whole  of  the  time,  and 
the  thermometer  being  almost  fixed  under  the  axilla.  As  soon  as  the 
temperature  rose  to  39.5°  the  patient  was  plunged  into  a  cold  bath. 
From  the  25th  of  February  to  the  3d  of  March  sixteen  baths  were  ad- 
ministered at  a  temperature  varying  from  twenty-one  to  twenty-five  de- 
grees (Centigrade),  and  the  duration  of  each  bath  was  twenty  minutes  on 
the  average.  The  patient  always  raised  the  temperature  of  the  water 
from  one  to  two  degrees,  and,  on  leaving  the  bath,  his  own  temperature 
fell  to  thirty-six  degrees.  After  several  fluctuations  and  much  anxiety 
on  the  part  of  the  medical  attendants,  the  patient  eventually  recovered 
completely. 

MENINGITIS  OF  THE  AGED. 

According  to  Prus,^  meningitis  of  very  old  persons  rarely  presents  the 
same  symptoms  as  do  the  forms  of  early  or  middle  life.  In  the  morning  the 
old  man  or  woman  is  stupid,  but  conscious ;  speech  is  thick,  and  there  is 
general  headache  and  moderate  fever.  The  warmth  of  the  body  is  nearly 
normal,  except  at  the  head,  where  it  is  markedly  increased.  In  the  even- 
ing it  is  elevated. 

The  eyes  are  injected,  and  there  is  low  delirium.  Incoherence  and 
restlessness,  during  the  night,  and  an  uneasiness  which  is  expressed  by 
walking  about  the  house  and  going  from  one  bed  to  the  other,  are  mani- 
festations which  are  characteristic.^  If  the  disease  is  to  end  fatally,  the 
patient  becomes  comatose,  and  dies  within  a  week,  or  twenty  days  at  the 
longest,  from  the  commencement  of  the  disease.     These  patients  very 


^Bull.  G6n.  de  Thferap.,  Mar.  30,  1875.     Med.  News,  1875. 

^  Quoted  by  Grisolle,  vol.  i.  p.  430. 

'  Eamskill  speaks  of  the  eccentric  behavior  of  these  patients,  who  may  use  the  spit- 
toon instead  of  the  chamber  pot,  or  commit  other  violations  of  decency.  In  one  case 
which  came  to  my  knowledge,  the  patient  urinated  against  the  bed-post,  and  went 
about  the  house  with  his  trowsers  always  unbuttoned. 


58  DISEASES   OF    THE    CEREBRAL    MENINGES. 

often  suffer  for  some  time  before  the  actual  attack,  when  there  may  be 
partial  paralysis,  slight  wandering  of  the  mind,  and  insomnia.  The 
general  indications  for  treatment  of  the  other  forms  are  applicable  ia 
these  cases. 

The  mental  disturbances  are  those  of  senile  dementia,  and  are  distinctly 
asthenic.  The  old  man  is  querulous  and  irritable.  He  delights  to  talk 
of  his  early  life,  but  cannot  tell  you  what  has  occurred  within  a  few 
hours.  If  the  condition  be  jjrofound,  he  will  sit  quietly  by  himself,  groan- 
ing and  complaining.  He  goes  frequently  to  stool,  or,  more  commonly, 
unconsciously  passes  his  feces  and  urine. 


ACUTE  GRANULAR  (TUBERCULAR)  MENINGITIS. 

Dr.  Robert  Whytt^  was  the  first  to  describe  this  disease,  and  so  satis- 
factorily did  he  do  so,  that  even  after  a  hundred  years  there  is  very  little 
to  add  to  his  accurate  description.  We  shall  have  to  study  the  disease  as 
occurring  in  two  different  ways.  It  may  be  primary,  and  have  a  doubtful 
tubercular  character,  or  may  occur  in  connection  with  some  thoracic  or 
abdominal  disease,  and  like  the  other  forms  of  meningitis,  may  be  confined 
to  the  base  or  convexity. 

Symptoms. — Though  many  of  the  symptoms  are  the  same,  there  are 
a  few  points  of  difference,  which  are  the  following : — 


Predominant  Indicative  Symptoms. 


VERTICAL. 


Vomiting,  constipation,  infrequent  or  Convulsions  with  intervals  occupied 
irregular  pulse,  unequal  pupils,  stra-  by  tremor,  twitching  of  limbs  and  mus- 
bismui.  cles  of  the  face,  turning  of  thumbs  in  on 

palms,  clenching  of  fists,  frequent  pulse'. 

When  the  base  is  involved,  the  symptoms  may  be  grouped  in  three 
stages,  Avhich  run  their  course  in  from  four  to  twenty-four  days.  The 
child  may  be  puny  and  delicate.  He  may  lose  flesh  and  complain  of 
headache.  His  skin  may  be  white  and  waxy,  and  there  may  be  a  ten- 
dency to  flushed  cheeks,  loss  of  appetite,  and  capriciousness  about  food, 
and  at  night  he  does  not  sleep  soundly,  but  starts  and  cries  out.  I  have 
known  children  to  seek  the  companionship  of  some  other  member  of  the 
family,  fearing  to  be  left  alone.  The  child  may  moan  in  its  sleep,  grind- 
ing his  teeth  and  lying  with  eyes  widely  opened.  During  the  day  he  is 
disinclined  to  play,  and  seeks  some  quiet  place  in  which  to  fall  asleep  or 
remain  by  himself.  Study  is  irksome,  and  so  are  all  other  forms  of  men- 
tal application.     Irritable  or  languid,  he  attracts  the  attention  of  the 


1  Works  of  Dr.  Whytt,  Edinburgh,  1768. 


ACUTE    GRANULAR    MENINGITIS.  59 

mother  by  his  behavior,  which  is  so  markedly  changed.  During  this 
period  I  have  found  that  headaches  and  crying-spells  are  not  uncommon 
precursors  of  the  actual  acute  disease,  which  may  begin  after  two  or  three 
months. 

Marshall  Hall,^  in  his  description  of  the  hydrocephaloid  diseases,  al- 
ludes to  the  importance  of  vomiting  as  an  early  symptom.  "The  most 
frequent  and  formidable  in  appearance  ...  is  vomiting.  Never, 
never  allow  vomiting  in  an  infant  to  pass  without  paying  the  utmost  at- 
tention, and  making  the  strictest  inquiry  in  reference  to  the  functions  of 
the  brain."  Vomiting  is  generally  the  first  and  most  important  symptom, 
and  convulsions  are  next  in  importance,  but  these  two  may  be  associated 
or  appear  alone.  Vomiting  may  be  frequent,  and  is  nearly  always  ac- 
companied by  an  aggravation  of  the  symptoms  of  the  premonitory  stage. 
Headache  and  increased  temperature  are  present,  and  are  very  decided 
evidences  of  the  gradual  development  of  the  trouble.  When  we  arrive  at 
this  stage,  which  lasts  two  or  three  days,  we  may  expect  the  appearance 
of  the  following  symptoms :  A  marked  rise  of  temperature,  say  from  101*^ 
to  105°  F.,  with  greatly  increased  pulse.  The  bowels  are  still  constipated, 
and  there  is  but  little  appetite.  The  patient  is  delirious  at  night,  and 
shrieks,  cries,  and  tosses  continually.  At  about  the  sixth  or  seventh  day 
of  the  disease,  there  are  various  local  troubles,  such  as  unequally  dilated 
pupils,  slight  strabismus,  but  no  actual  loss  of  consciousness  as  yet.  There 
is  a  slight  increase  in  the  evening  temperature,  and  the  pulse  is  irregular 
and  ranges  from  110  to  120.  The  tenth  day  finds  him  much  worse ;  his 
excited  condition  being  supplanted  by  one  of  stupidity.  He  does  not  re- 
cognize those  in  the  room,  and  is  utterly  indifierent  to  the  kind  attentions 
of  his  mother  or  nurse.  When  the  finger  is  drawn  across  the  skin  it 
leaves  a  vivid  red  mark,  which  has  been  considered  one  of  the  strong 
pathognomonic  signs.  The  pulse  is  greatly  accelerated,  and  perhaps 
reaches  170,  while  the  temperature  may  be  found  to  be  104°  or  105°.  His 
condition  during  the  tenth  and  eleventh  days  is  very  little  changed, 
though  the  apathy  is  if  anything  exaggerated.  The  belly  is  retracted, 
and  his  facies  is  highly  characteristic,  the  patient  having  a  worn  and 
pinched  look.  The  skin  is  dark  and  congested,  and  his  eyes  may  be  fixed 
and  immobile,  and  there  may  be  either  strabismus  or  a  rolling  upwards 
of  both  eyeballs,  so  that  a  large  part  of  the  sclerotic  is  exposed.  Subsul- 
tus  tendinum  and  "picking  at  the  bedclothes,"  with  involuntary  passage 
of  feces  and  urine,  are  grave  forerunners  of  a  fatal  termination.  The 
pupils  are  dilated,  the  pulse  small,  thready,  and  quick,  and  respiration  is 
very  slow.  The  temperature  is  still  high,  though  the  surface  may  be  cold 
and  clammy,  and  just  before  death  the  pulse  quickens  and  becomes  al- 
most imperceptible.  Slight  rigidity  now  becomes  apparent,  the  patient 
cannot  swallow,  stertor  follows,  and  then  death.     Marshall  HalP  tersely 

'  Lecture  on  the  Nervous  System  and  its  Diseases,  L.  and  E.  Philadelphia,  1836, 
p.  92. 
2  Op.  cit.,  p.  93. 


60 


DISEASES   OF    THE    CEREBRAL    MENINGES. 


describes  this  last  stage  as  follows :  "  The  third  stage  is  denoted  by  coma 
and  its  concomitaut  diminution  of  the  sentient  and  voluntary  system, 
and  eventually  of  the  powers  of  the  excito-motory   system.     There  are 

Illustrative  Chart  of  Temperature. 
Pulse  and  Kespiration  Variations  in  Acute  Granular  Meningitis. 


Days    of 
Disease. 

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A.  Indicates   sthenic  character. 

B.  Indicates  irregularity. 


blindness,  deafness,  deep  stupor,  absence  of  voluntary  motion.     At  first 
the  eyelids  are  constantly  half  closed,  but  dill  close  completely  on  touch- 


ACUTE    GRANULAR    MENINGITIS.  61 

ing  the  eyelash.  Afterwards  this  excito-motory  phenomenon  ceases. 
The  respiration  becomes  irregular,  alternately  suspended  and  sighing,  and 
at  length  stertorous.  The  sphincters  lose  their  power,  and  the  feces  and 
urine  are  passed  unconsciously."  The  appeai-ance  of  the  little  patient 
just  before  death,  is  unmistakable.  He  lies  with  knit  brow  and  flushed 
face,  one  side  of  which  is  drawn,  while  the  eyes  are  fixed  and  glassy,  and 
utterly  devoid  of  expression. 

The  duration  of  the  disease  rarely  exceeds  twenty-four  days.  It  will  be 
well  to  dwell  more  fully  on  certain  symptoms.  Temperature. — There 
seems  to  be  at  first  an  elevation  of  temperature,  which  lasts  through  the 
first  few  days,  say  three  or  four,  and  after  this  time  the  temperature  falls, 
until  the  sixteenth  or  eighteenth  day,  when  it  may  either  go  much  lower, 
or  be  again  increased.  The  variations  are  between  the  normal  standard 
98.2°,  and  105°.  It  however  rarely  reaches  this  high  point.  The  sur- 
face temperature  of  the  body  is  much  diminished  during  the  latter  stages, 
but  the  head  is  always  hot.  Pulse. — Infrequent  and  irregular  pulse  is 
characteristic  of  the  earlier  stages  of  this  disease,  and  during  the  last  days 
there  is  increased  frequency  and  more  evenness.  During  the  first  two 
weeks  this  infrequency  is  to  be  observed,  but  after  this  it  may  steadily 
increase  ten,  twenty,  or  thirty  beats  more  each  day  until  at  last  it  cannot 
be  counted.  This  rule  is  not  without  its  exception,  and  I  have  found 
intervals  when  both  temperature  and  pulse  would  fall  to  the  normal  stand- 
ard, and  continue  so  for  some  days,  and  afterwards  rise.  The  pulse  is 
perhaps  more  rapid  when  the  disease  is  being  developed.  I  append  a 
chart,  which  will  enable  the  reader  to  see  at  a  glance  the  condition  of 
pulse,  temperature,  and  respiration  in  a  typical  case.  Various  modifica- 
tions of  the  cutaneous  circulation  have  been  dwelt  upon  by  Trousseau  and 
various  writers.  There  seems  to  be  an  extensive  disturbance  of  the  vaso- 
motor distribution  of  the  skin,  and  when  the  surface  is  brushed  or  rubbed 
ever  so  lightly,  or  even  when  slight  pressure  has  been  made  by  the  pillow, 
there  will  remain  a  bright  red  mark.  This  condition  of  the  cutaneous  cir- 
culation is  not  limited  to  the  integument  of  the  head,  but  may  be  present, 
especially  towards  the  end  of  the  disease,  over  the  whole  body.  Trous- 
seau^ has  called  attention  to  the  "  tache-cerebrale,"  which  is  the  name 
given  to  the  appearance  presented  when  the  finger  is  passed  over  the  sur- 
face, aud  a  red  line  remains. 

This  author  found  that  when  he  made  cross-markings  upon  the  abdomen, 
in  less  than  half  a  minute  the  portion  of  skin  which  he  had  touched  was 
suflTused  with  a  very  bright  red  tint,  which  disaj)peared  slowly,  the  lines 
made  by  the  finger-nails  remaining  after  the  others  had  faded  out.  The 
regions  where  this  redness  is  produced  most  easily  are  the  anterior  parts 
of  the  thighs,  the  abdomen  and  face.  Respiration. — There  are  the  usual 
fall  and  irregularity  which  accompany  collapse  of  all  kinds ;  and  sighing 
and  diminished  respiration  are  features  of  the  later  stages.  Sensorial 
Disturbances. — Headache  of  a  deep  and  throbbing  character  is  very  severe 

^  lectures  upon  Clinical  Medicine,  Am.  edition,  vol.  i.  p.  877. 


62  DISEASES   OF   THE    CEREBRAL    MENINGES. 

and  continuous,  lasting  until  coma  supervenes.  Various  indications  of 
the  patient's  sufferings  are  conveyed  by  his  behavior.  He  presses  his 
thumbs  against  his  temples,  or  locking  his  fingers  on  top  of  his  head, 
holds  his  head  in  his  hands,  and  gives  vent  to  suppressed  groans  or 
shrieks,  holding  his  breath  sometimes  as  if  fearing  that  the  very  effort  of 
expiration  might  increase  the  pain.  The  cry  of  the  patient  is  heart-rend- 
ing, but  I  am  not  disposed  to  agree  with  Trousseau  that  it  has  any  decided 
periodicity,  though  there  are  intervals  of  silence.  Hyperaesthesia  of 
the  scalp,  photophobia,  and  tenderness  of  the  muscles  at  different  parts 
of  the  body  are  usual  accompaniments.  Bertalot'  of  Pfeddersheim,  in 
an  analysis  of  24  cases,  has  found  photophobia  to  be  more  commonly  a 
symptom  of  the  later  stages,  in  which  conclusion  I  am  inclined  to  concur. 
The  psychical  symptoms  are  present  in  every  case,  though  delirium  is  not 
so  common  among  very  young  children,  and  when  it  does  occur  is  followed 
by  a  state  of  semi-consciousness,  and  finally  by  coma.  The  patients  will 
not  speak,  but  rebel  against  food  and  interference  of  any  kind,  and  after 
a  time  it  is  very  difficult  to  arouse  them.  One  very  interesting  fact  is 
that  the  coma  is  never  sudden,  but  is  preceded  in  every  instance  by  either 
somnolence  or  delirium  of  the  muttering  variety.  The  coma  sometimes 
becomes  less  profound  in  character,  and  there  may  be  a  lucid  interval  be- 
fore death.  Motorial  Disturbances. — The  eyes  are  nearly  always  affected ; 
and  the  ocular  trouble  is  either  strabismus,  ptosis,  or  a  pupillary  change. 
The  former  is  an  early  symptom,  and  is  probably  the  first  indication  of 
paralysis  of  any  kind,  and  is  seen  most  perfectly  when  a  patient  is  awa- 
kened or  aroused.  The  pupils  are  sometimes  unequally  dilated,  but  when 
the  coma  supervenes  dilatation  is  complete ;  pupillary  changes  are,  how- 
ever, by  no  means  constant. 

Unilateral  paralysis  is  not  rare  ;  some  of  the  facial  muscles  being  alone 
affected,  or  there  may  be  extensive  hemiplegia,  which  is  an  advanced 
symptom.  Spastic  contractions  are  evidences  of  a  condition  of  central 
irritability ;  and  rigid  flexion  of  the  muscles  of  the  thumb,  or  muscles 
of  the  sub-occipital  region,  are  examples  of  this  kind.  The  patient 
commonly  lies  with  his  thumbs  drawn  into  the  palm  of  the  hand 
and  covered  by  the  fingers,  and  it  is  sometimes  difficult  to  open  the 
hands. 

I  have  alluded  to  convulsions,  and  in  addition  may  say,  that  they  are 
more  prominent  in  the  first  four  days,  and  vary  in  severity  if  the  coma 
be  either  very  deep  or  there  is  a  condition  of  semi-consciousness.  In  the 
latter  case  they  may  involve  isolated  groups  of  muscles. 

Ophthalmoscopic  Signs. — Bouchut,^  Galezowski,^  and  numerous  observ- 
ers have  called  attention  to  the  value  of  the  ophthalmoscope  as  an  in- 
strument for  diacrnosis  in  tubercular  meningitis.     The  latter  has  found 


1  Jahrbuch  fiir  Kinderheilkunde,  B.  9,  H.  3. 

2  Da  Diagnostic  des  Maladies  du  Systeme  nerveux  par  I'Ophthalmoscope.     Paris, 
1866. 

3  Arch.  G^n.,  1867,  vol.  ii.  p.  262. 


ACUTE    GRAXULAR    MEXIXGITIS.  63 

two  forms  of  neuritis  as  evidences  of  this  disorder  ;  one  a  peri-neuritis, 
and  the  other  an  inflammation  of  the  optic  nerve  itself.  Whiteness 
about  the  papilla,  deposits  of  granular  matter  in  the  choroid,  and  tortu- 
osity of  the  retinal  vessels,  are  appearances  which  have  been  described 
by  others.  FrankeP  and  Steffen  found  tubercle  in  the  choroid  some 
weeks  before  the  invasion  of  the  disease  ;  and  Broadbent,^  in  examining 
the  fundus,  discovered  that  the  optic  disks  were  dusky  red,  and  mottled 
by  white  spots ;  and  the  retinal  veins  were  enlarged,  while  the  arteries 
were  very  small.  Tubercular  meningitis  of  the  convexity  rarely  presents 
ophthalmoscopic  signs,  though  every  form  of  convexity  disease  may 
occasionally  give  rise  to  retinal  trouble. 

ACUTE   GRANULAR   MENINGITIS   OF  THE   CONVEXITY. 

In  the  table  I  presented  when  speaking  of  the  basal  division  of  this 
disease,  I  mentioned  the  prominent  symptoms  of  this  variety.  When  I 
add  that  delirium  and  other  decided  psychical  symptoms  are  highly 
characteristic  of  inflammation  of  the  vertical  region,  I  have  described 
the  difference  between  the  two  forms.  This  variety  runs  its  course 
in  a  much  shorter  time,  death  generally  resulting  in  from  a  week  to  ten 
days. 

When  the  malady  (either  basal  or  vertical)  occurs  in  conjunction  with 
certain  tubercular  affections  of  the  lungs  or  peritoneum,  there  are  local 
symptoms  which  precede  those  of  the  meningeal  disorder,  but  the  inva- 
sion of  the  disease  is  often  very  sudden.  Constipation,  followed  by  a  ty- 
phoid state  and  drowsiness,  are  the  precursors  of  meningitis  when  ante- 
cedent lung  disease  has  existed.  ISTot  only  may  children  be  subject  to  this 
disease,  but  adults  are  as  well ;  and  we  sometimes  find  it  as  a  sequence  of 
various  zymotic  diseases,  typhus  or  typhoid,  remittent  and  other  fevers,  as 
well  as  pulmonary  tuberculosis.  A  marked  elevation  of  the  evening  tem- 
perature, incomplete  hemiplegia,  vomiting,  or  convulsions,  are  the  promi- 
nent features  of  such  a  termination.  Strabismus,  unequal  mydriasis,  high 
pulse,  and  temperature,  with  some  of  the  other  symptoms  which  charac- 
terized the  disease  in  the  child,  that  have  already  been  described,  are 
generally  present. 

It  is  sometimes  so  insidious  in  its  approach  and  development  as  to 
puzzle  the  observer.  The  phthisical  patient  may  become  listless,  drowsy, 
or  complain  of  headache.  He  often  wanders  and  gives  way  to  a  mild 
form  of  delirium,  which  appears  during  the  latter  part  of  the  day. 
This  complication  may  occur  during  the  early  stages  of  the  pulmonary 
affection. 

Causes. — The  question  of  diathesis  naturally  arises  before  any  other, 
and  we  are  immediately  puzzled,  for  on  one  side  we  find  that  Rokitansky, 

^  Virchow's  Jahresbericht,  1869,  p.  621. 

^  Trans,  of  London  Pathological  Society,  vol.  xxiii.  p.  216. 


64 


DISEASES    OF  THE   CEREBRAL    MENINGES. 


Kobin,  Empis,  Clark,  and  others  consider  the  disease  not  to  be  directly 
connected  with  the  tuberculous  diathesis,  and  they  go  so  far  as  to  ques- 
tion the  identity  of  the  granular  deposit  in  the  brain  with  tubercle ; 
while  arrayed  against  them  are  Rilliet  and  Barthez,  Grisolle,  and  a  host  of 
others  who  are  equally  positive  that  it  is  in  every  case  an  expression  of 
tuberculosis.  Leaving  the  discussion,  which  is  by  no  means  settled,  as 
the  nature  of  the  deposit  needs  much  more  investigation  than  it  has  re- 
ceived, we  may  assume  that  the  affection  is  usually  associated  with  a 
"  scrofulous  "  cachexia  ;  that  it  appears  among  children  who  are  badly 
nourished,  and  in  whom  the  nervous  diathesis  is  well  developed.  That 
exposure,  insufficient  food,  and  various  exciting  causes,  such  as  dentition 
and  over-study,  produce  it,  no  one  will,  I  think,  deny.  In  some  in- 
stances— and  these  are  by  no  means  few — it  is  impossible  to  find  any 
hereditary  tuberculous  history.  As  to  age,  we  may  consider  that  the 
so-called  primcwy  tubercular  meningitis  rarely  occurs  after  the  fourteenth 
year,  and  it  is  probable  that  a  great  many  of  such  cases  are  unattended 
by  tubercle,  but  by  a  granular  deposit  of  simple  character ;  and  primary 
tubercular  meningitis  in  after  life  is,  I  think,  a  genuine  tubercular  disease. 

Watson^  makes  the  statement  that  fifty  children  are  attacked  within 
the  first  five  months  of  life  to  every  one  after  that  time.  I  have  found 
it  to  be  more  common  after  the  first  year,  between  the  first  dentition  and 
the  fifth  year,  though  general  practitioners  who  see  more  of  these  cases 
undoubtedly  find  them  before  that  time.  In  large  cities  the  mortality  is 
undoubtedly  greatest  in  the  summer  months,  when  diarrhoeal  as  well  as 
other  diseases  and  high  temperature  are  conducive  to  its  development. 
In  the  year  1871,  in  the  city  of  New  York,  84  deaths  from  "  tubercular 
meningitis  "  (the  reported  exciting  cause  being  "teething  ")  are  recorded 
in  the  Health  Board  Rej^orts,  and  the  greatest  number  were  found  be- 
tween the  sixth  and  fourteenth  years,  a  fact  which  seems  to  be  irre- 
concilable with  the  statement  that  it  is  generally  connected  with  the  first 
dentition.^ 

The  table  presented  below  demonstrates  that  males  are  much  more 
frequently  affected  than  females,  and  of  169  deaths  91  were  of  males  and 


^  Practice  of  Physic,  p.  270. 

2  An  inspection  of  the  table  prepared  by  Dr.  C.  P.  Russell,  in  the  report  of  the 
Board  of  Health  of  the  City  of  New  York  for  1870,  will  enable  the  reader  to  per- 
ceive the  preponderance  of  mortality  before  the  second  year  of  life. 


Nati 

U.S. 

vity. 
For'n. 

Color- 
ed. 

Under 

1 
Year. 

1 

2 

3 

4 

5 

10 

15 

20           2S 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F 

M. 

F. 

M. 

F. 

M.  F. 

M. 

F. 

M.   F. 

M.   F. 

M.   F. 

M.    F.  M.   F. 

82 

70 

9 

- 

30 

28 

17 

21 

14 

9 

8      5 

4 

7 

7      3 

1 

4      4 

. .      1    .  .     .  . 

Also  five  males  of  30,  one  of  50,  and  one  of  55;  this  cause  of  death  was  .62  per 
cent,  of  the  combined  cause. 


ACUTE   GRANULAR   MENINGITIS.  65 

78  of  females.  Bertalot,  already  referred  to,  found  that  of  his  24  cases 
fourteen  were  boys  and  ten  were  girls.  Two  cases  occurred  in  the  first 
year  of  life,  seven  in  the  second,  five  in  the  third,  three  in  the  fourth, 
three  in  the  twelfth,  and  one  each  in  the  fifth,  ninth,  tenth,  and  fourteenth 
years.  The  youngest  patient  was  ten  weeks  old,  and  twenty-two  out  of  the 
twenty  four  were  attacked  between  November  and  the  end  of  June.  The 
children  were  all  more  or  less  delicate,  they  had  frequently  grown  up 
under  bad  hygienic  conditions,  and  were  generally  scrofulous  or  scrofulo- 
rachitic  In  twelve  there  was  a  distinct  hereditary  predisposition  to 
tuberculosis  ;  two  cases  supervened  upon  chronic  coxitis  ;  one  upon  trau- 
matic erysipelas  ;  two  upon  pertussis ;  one  uj^on  measles  ;  and  one  upon 
the  first  signs  of  dentition. 

There  are  certain  physical  appearances  belonging  to  children  predis- 
posed to  these  forms  of  disease  which  should  not  be  passed  unnoticed. 
In  nearly  all  of  the  cases  I  have  seen  the  head  of  the  subject  was  pecu- 
liarly long  and  large.  The  hair  was  usually  silky  and  fine,  and  of  light 
color,  and  in  some  cases  hip  disease  and  like  troubles  had  been  noted. 

Morbid  Anatomy  and  Pathology. — From  the  immense  mass 
of  confused  testimony  before  us  (for  the  disease  has  been  described  by 
nearly  every  writer,  since  the  time  of  Hippocrates),  it  is  extremely  diffi- 
cult to  say  whether  the  posi-viortem  appearances  are  always  those  of  a 
tuberculous  character,  or  whether  the  granular  substance  is  non-tubercu- 
lous, or  again  whether  in  some  cases  there  is  tuberculous  dejDOsit  and  in 
others  simple  granular  collections.  Paisley,  who,  Watson  says,  was  the 
first  to  clearly  describe  the  affection  without  saying  much  about  its  tuber- 
culous nature,  has  given  us  a  very  admirable  collection  of  facts  bearing 
upon  its  morbid  anatomy. 

Gerhard/  one  of  the  early  medical  writers  of  this  country,  says  :  "  It 
was  not  known,  previously  to  the  researches  of  Dr.  Rufzand  myself,  that 
the  tuberculous  character  of  the  disease  was  anything  but  a  mere  compli- 
cation." Guersent,  Dance,  Hennis,  Greene,  and  others  shared  in  Ger- 
hard's opinion,  that  tubercular  meningitis  was  a  "  strumous"  disease. 

Rufz^  collected  40  cases,  and  in  every  instance  there  was  complicating 
pulmonary  tuberculosis. 

Fenwick's^  tables  are  valuable  in  displaying  the  distribution  of  tubercle 
in  the  affection. 

In  one  of  these,  sixteen  cases  of  meningitis  occurring  in  tubercular 
patients  are  detailed  in  which  tubercle  was  found  in  the  lungs  and  other 
organs,  but  not  in  the  brain. 

In  these  cases,  of  which  ten  were  males  and  six  females,  there  was  tu- 
berculous deposit  in  the  lungs  in  every  instance,  and  in  some  of  them 
other  organs  were  affected.  Positively  nothing  like  tubercle  could  be 
found  in  the  brain,  but  this  organ  was  either  congested  or  anaemic.     The 

^  Dunglison's  Prac.  of  Med.,  vol.  ii.  p.  243. 

2  Quoted  by  Marshall  Hall,  p.  94. 

'  St.  George's  Hosp.  Eeports,  vol.  vii.  p.  35. 


66  DISEASES   OF   THE   CEREBRAL   MENINGES. 

membranes  were  "  wet,"  and  the  ventricles  contained  fluid.  Four  cases 
were  under  ten  years  of  age;  three  between  ten  and  twenty,  and  three 
between  twenty  and  thirty ;  four  were  in  the  fourth  decade,  and  one  in 
the  fifth  and  sixth.  In  other  cases  brought  forward  by  him  of  general 
tuberculosis,  it  was  found  that  of  fifty-four  examined,  nearly  four-fifths  of 
the  number  were  below  twenty-five  years.  AH  of  these  fifty-four  had 
tuberculous  deposits,  both  in  the  brain  and  other  organs. 

The  seat  of  the  granular  deposit  seems  to  be  chiefly  the  arachnoid  and 
pia  mater,  though  the  dura  mater  has  been  found  as  well  to  be  the  site  of 
granular  accumulation.  It  is  scattered  mostly  along  the  base  of  the  brain 
and  about  the  large  arteries,  where  it  may  be  found  to  consist  of  masses 
of  little  round  pearly  or  yellowish  bodies  which  may  be  almost  as  small 
as  grains  of  coarse  corn  meal.  The  meningeal  arteries  are  dotted  over 
with  these  granules,  and  when  the  arachnoid  is  raised  numerous  under- 
lying miliary  granules  are  exposed. 

Fm  12. 


Tuberculous  Matter  about  the  Vessel-.    (Cornil  and  Ranvier.)-A.  Tuberculous  deposit. 
B.  White  blood-corpascles.       C.  Granular  contents  of  vessel. 

The  membranes  are  all  more  or  less  congested  and  dotted  with  opaque 
spots  or  patches.  The  cortex  is  hyperseraic  and  the  ventricles  distended 
by  fluid.  Their  ependyma  is  toughened  and  rough,  and  presents  a  gran- 
ular appearance  which  may  be  likened  to  that  of  white  shark's  skin. 

Softening  of  various  parts  of  the  brain,  the  nerve  trunks  and  optic 
commissure  are  not  uncommon  evidences  of  the  violence  of  the  disease. 
Patches  of  false  membrane  which  contain  in  their  meshes  these  granular 
bodies  are  scattered  over  the  convexity  and  base,  and  render  the  removal 
of  the  brain  or  its  membranes  separately  a  somewhat  difficult  matter.  The 
lungs,  or  other  organs,  may  also  present  indications  of  tuberculous  matter. 

Rendu '  affirms  that  whenever  there  is  paralysis  of  permanent  form  there 
must  be  some  arterial  obliteration  from  fibrinous  exudation  and  consequent 
softening,  and  he  does  not  believe  that  scattered  granulations  or  ventricu- 
lar effusion  are  alone  sufficient  for  its  causation. 

1  Review  in  Gaz.  des  Hopitaux,  Jan.  15,  1873. 


ACUTE   GRANULAR   MENINGITIS.  67 

It  is  rarely  possible  to  very  closely  localize  limited  deposits  before  death, 
but  occasionally  this  may  be  done. 

A  very  interesting  case  is  reported  by  Raymond  which  presented  seve- 
ral suggestive  points.  One  was  that  the  motor  centre  of  the  right  arm 
was  the  seat  of  granular  lesion,  and  that  there  was  paralysis  of  that  mem- 
ber.    This,  then,  is  an  exception  to  the  rule  to  which  I  have  just  referred. 

"  The  patient,  a  man  twenty-two  years  of  age,  was  admitted  into  the 
hospital  m  the  early  part  of  the  month  of  January  last,  and  then  presented 
obvious  symptoms  of  pulmonary  tuberculosis,  not,  however,  very  pro- 
nounced. The  affection,  indeed,  seemed  to  be  progressing  slowly.  He 
was  thin,  pale,  coughed  a  good  deal,  and  was  a  little  feverish. 

"  On  January  28  he  began  to  complain  of  violent  pain  in  tiie  right  hy- 
pochondrium,_and  two  days  later  vomiting  came  on.  This  recurred  fre- 
quently, the  ejected  matter  having  a  greenish  color.  At  the  same  time 
he  suffered  from  severe  headache,  which  affected  chiefly  the  left  side  of 
the  head.  Fever  then  showed  itself,  the  temperature  rising  to  140  °  ;  the 
pulmonary  lesions  developed  more  rapidly,  and  the  general  condition  be- 
came much  worse.  On  March  24  he  complained  of  great  pain  in  his 
right  arm,  which  seemed  to  be  very  heavy;  at  times  he  had  great  difficulty 
in  moving  it.  On  March  25  there  were  fresh  pains  in  the  arm,  and  motor 
paralysis  was  complete,  sensibility  being  retained.  In  the  evening,  with 
a  great  effort,  he  succeeded  in  raising  his  arm  to  his  head.  The  paralysis 
of  the  arm,  up  to  the  time  of  his  death,  presented  the  character  of  inter- 
mittence.  There  never  existed  any  trace  of  paralvsis  in  the  right  leg  nor 
in  the  left  arm  or  leg.  Perhaps  there  was  a  slight  degree  of  loss  of  power 
m  the  bucco-labial  muscle  of  the  right  side,,  and  a  slight  deviation  of  the 
tongue  to  the  left,  but  these  synjptoms  were  a  little  doubtful.  In  the 
whole  case,  there  was  nothing  else  comparable  with  the  paralysis  of  the 
arm,  which  was  indisputable.  The  patient  died  on  April  4. 
_  "  At  the  necropsy,  far  advanced  tubercular  lesions  were  revealed  in  the 
right  lung,  and  the  membranes  of  the  brain  were  found  to  be  the  seat  of 
tubercular  granulations.  These  were  found  in  the  j^ia  mater  over  the 
right  lobe,  and  there  they  were  disseminated  along  the  parietal  branch  of 
the  Sylvian  fissure.  On  the  left  side,  in  addition  to  the  tubercular  granu- 
lations, there  existed  some  meningitis  with  purulent  deposits.  The'  men- 
ingitis was,  if  it  may  be  so  said,  circumscribed  and  localized  on  two  con- 
volutions, the  anterior  and  posterior  marginal  near  the  paracentral  lobe. 
There  the  tubercular  granulations  were  very  numerous,  and  formed  a  sort 
of  tumor.  The  pia  mater,  covered  with  pus,  adhered  closely  to  the  sub- 
jacent cerebral  tissue.  In  other  parts,  where  there  were  granulations 
there  was  no  vestige  of  meningitis.  Xo  other  cerebral  lesions,  foci  of 
softening,  or  obliteration  of  capillaries,  could  be  discovered.  There  was 
a  snaali  amount  of  fluid  in  the  ventricles,  but  nothing  to  note  in  the  spinal 
cord  or  nerves  of  the  arm. 

"Such  are  the  facts  of  this  case,  which  may  be  summed  up  as  follows: 
Motor  paralysis  of  the  right  arm,  somewhat  intermittent  in  the  sense  that 
It  was  at  times  complete,  and  at  other  times  less  absolute;  and  to  explain 
this  paralysis  no  other  lesion  than  the  tubercular  meningitis  in  the  region 
of  the  motor  centre  of  the  arm."^ 


'  London  Med.  Record,  July  15,  1876.     Abstract  from  Le  Progres  Medical,  April 
22,  1876.  ^ 


68  DISEASES   OF   THE   CEREBRAL   MENINGES. 

Landouzy  has  collected  a  large  number  of  valuable  cases,  showing  the 
possibility  of  localization  sometimes  in  tubercular  meningitis,  and  has  pre- 
sented 43,  in  which  partial  convulsions  predominated  in  23  cases.  In  these 
the  distribution  was  as  follows  : 

The  face  alone,  once ;  the  face  and  arm,  twice  ;  the  face,  arm,  and  leg, 
five  times ;  the  arm  alone,  six  times ;  the  arm  and  leg,  eight ;  the  leg  alone, 
once. 

^In  half  of  these  cases  the  convulsions  were  limited,  in  some  cases  the 
partial  convulsions  were  preceded  by  those  of  a  general  character.  He  was 
enabled  to  diagnose  the  seat  of  the  trouble  in  all  of  these  cases. 

Prognosis. — No  inflammatory  disease  of  the  brain  or  its  membranes 
is  more  serious  or  rapidly  fatal  than  is  this.  The  termination  is  in  death  in 
from  two  to  three  weeks,  though  very  rarely  recovery  may  take  place  be- 
fore the  disease  has  gone  beyond  the  period  of  invasion.  The  ophthal- 
moscope is  of  service  at  this  time.  If  there  be  optic  neuritis,  and 
basilar  meningitis  is  suspected,  there  is  very  little  hope  to  be  derived 
from  such  an  examination  ;  if  the  child  recovers,  it  will  be  with  impaired 
intellect,  epilepsy,  or  some  other  serious  life-long  trouble. 

An  anonymous  writer  in  the  Gazette  Medieale  upon  the  treatment  of 
tubercular  meningitis,  says  that,  in  a  practice  of  thirty  years,  he  has  seen 
between  eighty  and  ninety  cases,  and  during  that  time  there  were  but  two 
recoveries.^     Bierbaum^  has  reported  three  recoveries. 

Diagnosis. — This  disease  may  be  mistaken  at  different  stages  for 
several  other  acute  conditions,  viz. : — 

A.  Typhoid  fever — typhus  fever. 

B.  Scarlet  fever  or  smallpox. 

C.  Pleurisy  or  pneumonia. 

D.  Eccentric  irritation,  such  as  that  produced  by  worms,  etc. 

E.  Other  forms  of  meningitis. 

F.  Exhaustion. 

G.  Syphilis. 

A.  Typhoid,  in  some  of  its  forms,  or  typho-pneumonia,  may  resemble 
tubercular  meningitis,  either  of  the  primary  or  secondary  forms.  This  is 
especially  the  case  when  typhoid  symptoms  are  added  to  those  of  phthisis. 
The  irregular  varieties  of  typhoid  are  attended  by  absence  of  diarrhoea, 
tympanites,  and  other  abdominal  symptoms.  The  eruption  of  typhoid  may 
also  resemble  the  tache  cerebrale  of  this  form  of  meningitis,  but  it  is 
usually  confined  to  the  chest  and  abdomen,  and  is  an  early  symptom. 
Typho-pneumonia  may  bear  a  close  resemblance  to  secondary  tubercular 
meningitis,  and  this  is  particularly  the  case  if  moist  I'ales  can  be  heard  all 
over  the  chest,  and  there  is  some  dullness  at  the  apex  ;  certain  points  are 
to  be  borne  in  mind,  however,  that  will  put  the  diagnostician  on  his  guard. 
Uncomplicated  typhoid  is  a  disease  of  longer  duration,  and  the  abdominal 

'  Contribution  a  I'etude  des  Convulsions,  etc,  Paris,  1876. 
2  Gazette  Medieale,  1871,  412. 
=*  Deutsche  Klinik,  1873,  184. 


ACUTE   GEAXULAR   MENIJTGITIS.  69 

symptoms  are  usually  marked.  There  is  tenderness  in  tlie  left  iliac  fossa, 
high  evening  temperature,  nose-bleed,  and  usually  slight  head  symptoms, 
which  vary.  The  eruption  fades  away  under  pressure,  instead  of  being 
produced  by  pressure  or  contact,  as  is  the  case  in  the  meningeal  difBculty, 
and  the  prodromal  symptoms  of  typhoid  are  not  nearly  so  marked  as 
those  of  the  other  disease. 

Typhus  fever  may  sometimes  make  the  diagnosis  exceedingly  difficult ; 
for,  as  we  know,  its  duration  is  about  that  of  the  tubercular  trouble,  and 
head  symptoms  are  its  marked  feature.  The  general  absence  of  pulmo- 
nary symptoms,  the  appearance  of  the  dark  rash,  and  the  antecedents  of 
the  patient  offer  us  guides. 

B.  Scarlet  fever,  which  sometimes  begins  with  vomiting  and  early  head 
symptoms,  may  puzzle  the  observer.  The  throat  trouble,  the  early  appear- 
ance of  the  eruption,  the  peculiar  "strawberry  tongue"  which,  as  far  as  I 
am  aware,  is  found  in  but  two  diseases,  diphtheria  and  scarlet  fever,  and 
the  high  and  continued  elevation  of  temperature  during  the  eruption,  are 
sufficient  to  put  the  medical  man  upon  the  alert. 

Smallpox,  without  the  eruption,  may  sometimes  mislead  us.  The  pro- 
dromal symptoms,  pain  in  the  back,  vomiting,  and  headache,  are  different 
from  the  same  symptoms  in  tubercular  meningitis.  They  are  more  severe, 
and  may  immediately  usher  in  coma.  Bleeding  from  the  nose  and  mouth 
I  have  witnessed  in  three  patients.  This  form  of  smallpox  is  quite  rare. 
In  the  course  of  nine  years,  during  which  I  was  connected  with  the 
Health  Department  of  the  City  of  New  York,  I  saw  over  one  thousand 
cases  of  the  disease,  and  I  do  not  remember  having  encountered  but  ten 
or  twelve  cases  of  this  terrible  form  of  variola.  These  cases  were  all 
adults.  If  pronounced  smallpox  should  suggest  the  other  affection,  it 
will  be  found  that  in  two  or  three  days  any  blush  eruption  (which  could 
hardly  be  mistaken  for  the  maculse  of  tubercular  meningitis,  which  is  a 
late  symptom)  will  develop  so  that  the  characteristic  vesicles  may  be 
seen.  In  both  scarlet  fever  and  smallpox  the  history  of  exposure  often 
supplies  the  link. 

C-  Pneumonia  and  pleurisy  can  Only  be  mistaken  when  we  neglect  to 
take  into  account  the  chill,  pain  in  the  side,  and  physical  signs.  The  latter 
disease  may  sometimes  be  supposed  to  exist ;  for  Gee  has  heard  the  fric- 
tion sound  of  pleurisy  in  tubercular  meningitis. 

D.  Reflex  irritation  from  ascarides  may  produce  many  of  the  early 
symptoms  which  also  indicate  tubercular  meningitis,  and  even  convulsions 
may  appear ;  but,  unlike  the  tubercular  disease,  there  is  no  further  pro- 
gress. The  use  of  an  anthelmintic  will  clear  up  the  diagnosis,  if  we  have 
reason  to  suspect  these  parasites. 

E.  From  simple  meningitis  we  may  distinguish  the  disease  chiefly  by 
the  late  ajDpearance  of  the  delirium.  The  j)atient  lapses  into  unconscious- 
ness in  the  former  disease  in  two  or  three  days,  while  in  tubercular  menin- 
gitis the  acute  mental  disturbance  is  not  so  immediate.  Acute  meningitis 
runs  its  course  usually  in  a  week. 

Various  intracranial  diseases  may  resemble  at  different  times  the  dis- 


70  DISEASES   OF   THE   CEREBEAL   MEXIXGES. 

ease  under  consideration  ;  but  as  I  propose  to  treat  of  these  hereafter,  it 
will  be  well  to  omit  them  here. 

F.  Exhaxidion. — The  excitement  aroused  in  England  by  the  Penge 
case  gives  this  part  of  the  subject  decided  importance.  It  will  be  remem- 
bered that  one  Louis  Staunton,  with  two  accomplices,  one  of  whom  was 
his  brother,  and  the  other  a  woman  with  whom  he  was  living  upon 
terms  of  criminal  intimacy,  starved  to  death  his  wife,  and  that  they 
all  narrowly  escaped  capital  punishment  or  transportation.  The 
coroner's  jury  decided  that  the  real  cause  of  her  death  was  starvation, 
while  several  distinguished  medical  men  contended  that  she  had  died 
from  tubercular  meningitis,  but  did  not  deny  that  she  had  been  neglected. 
The  disputed  points  seemed  to  be,  the  rapid  emaciation  and  great  anai- 
mia  of  the  tissues,  as  well  as  disappearance  of  subcutaneous  fat.  Her 
symptoms  before  death  were  drowsiness  passing  into  coma,  stertor, 
rigidity  of  one  arm,  and  inequality  of  pupils.  These  symptoms  appeared 
but  shortly  before  death,  and  were  supposed  by  Dr.  Greenfield,^  who 
made  a  most  sensible  and  convincing  communication  to  the  Lancet,  not 
to  account  for  starvation  alone,  but  to  be  probably  due  to  tubercular 
meningitis. 

Opposed  to  him  are  several  observers  Camong  them  Virchow,  who  re- 
viewed the  English  testimony)  who  held  that  the  great  emaciation,  loss 
of  weight  of  the  internal  organs,  emptiness  of  the  cavities  of  the  heart, 
and  certain  forms  of  congestion  were  clearly  indicative  of  starvation. 
Greenfield  proved,  I  think,  that  none  of  these  appearances  were  sufficient 
in  themselves  for  us  to  say  definitely  that  they  were  due  to  starvation  ; 
that  they  may  often  be  a  result  of  exhausting  disease ;  that  the  congestion 
witnessed  was  an  ordinary  post-mo7'tem  appearance ;  and  finally  that 
tubercle  existed  in  the  lungs  and  brain  ;  while  in  the  latter  there  were  found 
primary  indications  of  softening  as  well  as  adhesion  of  the  meninges. 

Gee  calls  attention  to  forms  of  wasting  disease  with  profound  emacia- 
tion which  may  closely  simulate  tubercular  meningitis,  but  are  connected 
with  digestive  derangements  and  malnutrition ;  and  Sir  Wra.  Gull,  in 
one  of  the  English  hospital  report^,  brought  forward  some  years  ago, 
several  cases  of  hysterical  anorexia,  with  emaciation  ;  and  in  the  pro- 
found form  of  cerebral  anemia  there  can  be  symptoms  which  may  resem- 
ble some  of  those  expressed  in  tubercular  meningitis  so  greatly,  as  to 
possibly  lead  to  an  error  in  diagnosis. 

G.  A  case  of  cerebral  syphilitic  meningitis  which  closely  resembled 
tubercular  meningitis  was  reported  by  Webber.  There  were  decided  pul- 
monary troubles,  and  the  tache  cerebral,  but  antecedent  pain  for  one  year, 
mental  dulness,  etc.,  and  recovery  under  specific  treatment  cleared  up 
the  case. 

Treatment. — More  can  be  done  for  the  patient  in  the  early  stages 
than  at  any  other  time.  Cod-liver-oil,  phosphorus,  a  nitrogenous  diet,  and 
preparations  of  iodine  are  all  of  great  service.    The  syrup  of  the  iodide  of 

'  London  Lancet,  Oct.  6,  1877. 


CHRONIC   CEREBRAL   MENINGITIS.  71 

iron  is  an  excellent  remedy  in  the  earliest  stages,  if  we  recognize  the  sig- 
nificance of  the  somewhat  irregular  group  of  symptoms.  The  iodide  of 
potassium  has  been  by  many  used  during  later  stages.  Fleming  ^  reports 
a  cure  in  the  case  of  a  girl  two  and  a-half  years  old  by  large  doses  of  the 
iodide,  and  the  experience  of  others  is  also  encouraging.  Cold  to  the 
head  and  the  bromides  in  the  later  stages  are  of  greater  benefit  than  any 
other  remedies.  Ergot  has  been  successfully  used  by  Gibney  in  one  case 
of  so-called  tubercular  meningitis.  It  should  be  administered  in  full  doses 
often  repeated.  It  will  be  found  that  a  drachm  may  be  given  every  three 
or  four  hours  without  producing  any  disagreeable  effects,  and  when  the 
disease  is  well  developed  I  have  been  able  to  do  more  with  this  drug  than 
any  other,  and  am  confident  that  a  case  of  simple  granular  meningitis  so 
treated  by  me  was  saved  by  its  early  and  free  administration.  Gee  recom- 
mends closure  of  the  eyelids  by  adhesive  plaster,  should  there  be  aoy 
ulceration  of  the  cornea.  Blistering,  bleeding,  and  violent  treatment  of 
any  kind  are  to  be  strongly  condemned ;  quiet  and  darkness  should  be  in- 
sisted upon  as  early  as  possible,  and  over-solicitous  friends  should  be  ex- 
cluded from  the  sick-room.  Food  of  a  liquid  form  may  be  given  by 
enemata,  or  by  the  mouth,  using  a  syringe,  and  being  careful  in  intro- 
ducing its  point  between  the  teeth. 

CHRONIC  CEBEBRAL  MENINGITIS. 

This  comparatively  rare  disease,  which  may  be  either  the  result  of  acute 
meningitis,  or  develop  idiopathically,  or  after  head  injury,  is  of  slow  ap- 
pearance and  progress,  and  resembles  several  organic  diseases  of  the 
brain  proper,  among  them  softening,  general  paralysis,  and  brain  tumors. 

Symptoms. — One  of  the  early  symptoms,  especially  of  the  vertical 
variety,  is  headache,  which  varies  in  severity.  It  is  of  a  dull  character, 
and  is  seated  in  the  top  of  the  head,  and  is  increased  by  any  effort  which 
augments  the  cerebral  blood  pressure.  In  certain  cases  there  is  loss  of 
memory,  and  other  mental  symptoms,  which  resemble  closely  those  of 
general  paralysis  of  the  insane ;  and  this  mental  impairment  may  ter- 
minate in  dementia.  Insanity  is  by  no  means  a  rare  sequence  of  chronic 
meningitis,  and  may  follow  inconsiderable  early  symptoms.  In  an 
interesting  paper  from  the  pen  of  Mortimer  Granville^  seventeen 
cases  occurred  which  began  with  sunstroke.  In  all  of  these  insanity, 
usually  dementia,  followed  the  original  trouble.  The  vertical 
form  is  generally  complicated  with  encephalitis  and  muscular  para- 
lysis, as  well  as  spasms  and  twitchings  of  either  a  limited  group 
of  muscles,  or  the  arm  and  leg  of  one  side.  Tremor  and  sometimes  con- 
vulsions occur  after  a  short  period,  while  after  the  involvement  of  the 
vertical  cortical  substance  we  may  have  marked  motorial  symptoms, 
such  as  paralysis  with  contractures.  Paralysis  of  the  bladder  or  sphinc- 
ter ani,  takes  place,  so  that  the  patient  passes  his  urine  and  feces  in 
an  involuntary  manner.  The  disease  is  generally  progressive,  and 
there  is  an  increase  in  the  number  of  convulsions.     The  mental  decay 

1  British  Med.  Journal,  1871,  p.  443. 
*"  Brain"  Partviii. 


72  DISEASES    OF   THE   CEREBRAL   MENINGES. 

advances  rapidly,  and  the  patient  finally  dies,  at  the  end  of  a  few  months, 
iu  a  comatose  state.  The  basilar  form  of  disease  is  much  more  interest- 
ing than  that  of  which  I  have  just  spoken,  the  cranial  nerves  being  more 
or  less  involved ;  and  symptoms  of  cranial  paralysis  of  a  progressive 
character  form  a  distinguishing  feature  of  the  disease.  Thus,  in  thirteen 
cases  collected  by  Dr.  Cross,'  of  this  city,  the  third  nerve  was  paralyzed 
generally  on  the  left  side  in  nineteen  instances,  and  in  one  case  the  third 
pair  on  both  sides  was  affected.  In  nine  of  these  cases  strabismus  was 
noted  ;  in  five  of  which  it  was  external  and  existed  on  the  left  side.  The 
pupils  were  dilated  in  eight  instances,  and  contracted  once.  Obscureness 
of  vision  was  observed  to  be  prominent  in  four  cases,  while  ptosis  existed 
in  five,  occurring  once  on  both  sides.  Double  vision  was  present  in  many 
cases.  Blindness  occurred  once  in  the  left  eye,  which  was  the  result  of 
suppurative  choroiditis.  In  another  instance  there  was  loss  of  sight  in 
both  eyes.  I  may  select  four  of  Dr.  Cross's  cases,  which  represent  very 
fully  the  course  of  the  disease  : — 

Case  I. — A  young  man  came  to  the  clinic  who  was  affected  with  ex- 
ternal strabismus,  ptosis,  and  dilatation  of  the  pupil  of  the  left  eye.  He 
had  a  most  intensely  agonizing  pain  in  the  head,  vertigo,  frequent  attacks 
of  vomiting,  and  paresis,  if  not  paralysis,  of  the  arm  and  leg  on  the  same 
side.  He  was  treated  with  mercury  and  large  doses  of  the  iodide  of  po- 
tassium. In  a  short  time  the  pain  in  his  head  disappeared,  and  after  the 
lapse  of  a  few  weeks  the  paralysis  was  cured.  Two  or  three  months  sub- 
sequently he  reappeared,  with  a  corresponding  set  of  symptoms  in  the 
right  eye,  and  the  right  half  of  the  body,  and  with  pain  in  his  head  as 
severe  as  during  the  previous  attack.  He  was  again  treated  with  mercury 
and  the  iodide  of  potassium,  when  his  symptoms  again  disappeared,  and 
have  not  since  returned.  In  this  case  there  was  some  slight  suspicion  of 
syphilis. 

Case  II. — A  man,  twenty-eight  years  of  age,  came  under  my  charge 
some  two  years  ago.  At  that  time  he  was  suffering  from  pain  in  the 
head,  vertigo,  dilatation  of  the  pupil,  external  strabismus,  double  vision, 
numbness,  and  slight  paralysis  of  the  opposite  side  of  the  body.  As  far 
as  I  was  able  to  discern,  the  ocular  paralysis  was  confined  to  the  left  in- 
ternal rectus  muscle.  Until  within  a  few  months  prior  to  his  coming 
under  my  observation,  he  had  apparently  enjoyed  excellent  health,  with 
the  exception  of  a  severe  headache,  from  which  he  had  suffered  quite 
acutely.  He  stated  that  the  disease  with  which  he  was  afflicted  had  come 
on  slowly,  and  gradually  increased  in  degree.  He  acknowledged  that 
he  had  had  a  hard  chancre  several  years  previously. 

Under  the  influence  of  large  doses  of  the  iodide  of  potassium,  the  symp- 
toms rapidly  disappeared,  and  he  has  since  had  no  return  of  the  paralysis, 
although  he  afterwards  experienced  severe  headache,  which  disappeared 
under  treatment.     I  examined  hisretinsB,  but  found  no  disease. 

Case  III. — Shortly  after  this  I  was  consulted  in  regard  to  the  case  of 
a  gentleman,  thirty-five  years  old,  who  was  suffering  apparently  from 
symptoms  similar  to  those  observed  in  the  preceding  case,  with  the  excep- 
tion of  the  paresis  of  the  extremities.     He  had  well-marked  head-symp- 

1  Psychological  and  Medico-Legal  Journal,  New  Series,  vol.  ii.  p.  220. 


CHEONIC   CEREBRAL   MENINGITIS.  73 

toms  and  numbneirs,  which  was  limited  to  one  side  of  the  body,  but  the 
paralysis  was  confined  exclusively  to  the  ocular  muscles.  His  eyes  had 
heen  carefully  examined  by  an  eminent  ophthalmic  surgeon,  who  had 
informed  him  that  they  were  healthy,  and  that  his  trouble  was  probably 
cerebral.  He  was  a  very  robust  man,  and  had  apjDarently  suffered  from 
no  severe  disease  until  the  beginning  of  his  present  trouble.  On  question- 
ing him  closely,  he  stated  that  he  had  had  syphilis  twelve  years  ago,  for 
which  he  had  been  carefully  treated,  and  consequently  considered  himself 
cured.  When  I  first  saw  him,  the  double  vision  had  existed  several 
months,  and  during  that  time  had  been  almost  constantly  present.  I  did 
not  treat  this  patient,  and  consequently  do  not  know  the  result. 

Case  IV. — A  married  gentleman,  forty-one  years  of  age,  came  under 
my  care  in  1873.  He  was  descended  from  a  family  saturated  with  rheu- 
matism, and  gout,  and  five  of  whom  had  died  of  j)aralysis.  At  this  time 
he  was  suffering  from  myalgia,  which  I  found  to  be  located  in  the  muscles 
of  the  chest  and  back.  This  condition  lasted  about  three  months,  and 
then  disappeared  under  treatment.  He  stated  that  prior  to  this  time  his 
health  had  been  good.  He  had  been  temperate  in  his  habits,  and  had 
never  had  acute  articular  rheumatism,  gout,  nor  syphilis.  In  July,  1873, 
he  first  observed  that  the  pupil  of  the  right  eye  was  much  contracted. 
This  was  followed  by  headache,  vertigo,  and  obscureness  of  vision.  In 
December  he  came  to  my  office  and  informed  me  that  his  ocular  troubles 
had  increased.  At  that  time  his  condition  was  as  follows:  He  had  a  dull, 
heavy  pain  behind  the  eai's,  which  seemed  to  extend  along  the  base  of 
the  brain,  and  was  at  times  throbbing  in  character.  There  was  vertigo 
and  indistinctness  of  vision,  which  he  described  as  a  blurring  of  objects ; 
his  right  pupil  was  extremely  contracted,  and  did  not  respond  to  the 
stimulus  of  light.  Far  and  near  objects  were  very  indistinct,  and  ap- 
peared to  be  one  above  the  other.  AVhen  he  looked  at  the  pavement  it 
appeared  to  be  raised  above  its  natural  position.  There  were  double 
vision  and  strabismus. 

He  kept  his  head  constantly  turned  to  the  right  and  downwards,  in 
order  to  bring  the  axes  of  his  eyes  parallel.  All  his  organs  were  health}'', 
with  the  exception  of  his  brain.  There  was  apparently  partial  paralysis 
of  the  right  internal  rectus  and  right  inferior  oblique  muscles.  This 
gentleman  was,  by  my  advice,  carefully  examined  by  two  eminent  oph- 
thalmic surgeons  of  this  city,  both  of  whom  were  of  the  opinion  that 
there  was  no  disease  of  the  eyes.  An  important  point  in  this  connection 
is  the  fact  that  this  patient  had  been  in  the  habit  of  using  a  magnifying 
glass  with  the  affected  eye  to  examine  the  delicate  parts  of  machinery,  in 
order  to  see  that  they  were  properly  constructed  ;  and  this  operation  was 
conducted  in  a  dark  room,  lasting  several  hours  daily.  I  carefully  ex- 
amined this  patient's  spinal  cord  (as  I  always  do  in  all  these  cases),  but 
found  no  indications  whatever  of  spinal  disease.  I  ordered  him  to  take 
the  iodide  of  potassium,  in  fifteen-grain  doses,  three  times  a  day,  well 
diluted  in  water,  and  to  rapidly  increase  the  amount ;  but  the  first  dose 
caused  him  such  intense  nausea  and  vomiting  that  he  could  not  be  in- 
duced to  take  it  subsequently.  He  consequently  ceased  taking  any 
medicine,  and  for  some  time  he  continued  to  grow  worse,  all  his  symptoms 
increasing  in  severity.  He  was  obliged  to  give  up  his  business,  and  has 
since  passed  most  of  his  time  in  out-door  exercise. 

The  pupil  of  the  right  eye  remained  permanently  contracted  for  several 
months.    A  short  time  since  I  met  him,  and  he  told  me  that  he  was  about 


74  DISEASES   OF   THE   CEREBRAL   MENINGES. 

to  resume  his  business,  he  had  so  nearly  recovered.  His  pupil  was  still 
contracted,  but  not  to  the  same  degree  that  it  was  when  he  first  came 
under  ray  care  a  year  ao;o.  He  now  holds  his  head  straight ;  there  is  no 
apparent  strabismus,  although  his  wife  informs  me  that  he  occasionally 
sees  double.  His  headache  and  vertigo  have  disappeared.  The  only 
medicines  that  he  has  taken  during  this  period  have  been  tonics  and 
out-door  exercise.  I  made  particular  inquiry  in  this  case,  in  order  to 
discover,  if  possible,  a  constitutional  cause,  but  I  was  fully  satisfied  that 
none  existed'. 

Both  of  these  forms  of  meningitis  may  be  connected  with  cerebral 
growths  and  syphilitic  and  tuberculous  deposits. 

Causes. — Males  seem  to  be  oftener  affected  than  females,  and  the 
disease  is  ordinarily  one  of  adult  life.  It  is  connected  oftentimes  with 
the  tuberculous  diathesis,  and  is  not  rarely  dependent  upon  constitu- 
tional syphilis;  it  may  be  seemingly  idiopathic,  or  result  from  head 
injury,  exposure  to  the  sun,  intemperance,  the  acute  zymotic  fevers,  and 
the  other  causes  of  meningitis. 

Morbid  Anatomy  and  Pathology. — The  cerebral  meninges 
have  been  found  to  be  thickened,  adherent  to  each  other,  or  to  the  inner 
surface  of  the  cranial  bones,  with  effusions  beneath,  Avhich  have  under- 
gone partial  organization ;  sometimes  gummy  exudation  of  syphilitic 
origin  will  be  found  scattered  over  the  surface  of  the  brain,  or  calcareous 
plates  of  perhaps  an  inch  in  diameter  will  be  found  in  the  dura  mater, 
such  as  1  have  already  spoken  of  in  chronic  pachymeningitis.  If  the 
disease  has  involved  the  cortical  substance  of  the  brain,  we  may  discover 
patches  of  softening  of  variable  extent  and  depth,  and  perhaps  superficial 
abscesses.  At  the  base  of  the  brain  the  meningitis  is  not  generally  so 
diffuse,  but  occurs  in  circumscribed  spots,  the  cranial  nerve  trunks  being 
generally  softened  and  bound  down  by  bands  of  new  tissue.  In  a  case  of 
meningitis  following  sunstroke  ^Granville  found  very  interesting  osseous 
changes. 

"  Calvarium  strongly  adherent,  the  plates  dense ;  diploe  obliterated  ; 
membranes  very  vascular,  thickened  and  adherent  to  the  surface  of  the 
brain  along  the  median  fissure :  this  was  found  on  separation  to  be 
caused  by  three  or  four  bony  plates,  of  the  size  of  a  sixpence,  with  small 
spicul^e  passing  into  the  surface  of  the  brain  on  the  left  side ;  the  brain 
was  smaller  than  usual  and  weighed  only  forty-four  ounces ;  the  gray 
matter  was  deficient,  and  the  convolutions  flattened  and  apparently  not 
so  numerous." 

In  this  case  sunstroke  was  followed  by  headache,  most  intense  on  the 
left  side  of  the  head,  difficulty  of  articulation,  defective  memory,  and 
subsequent  symptoms  resembling  those  of  general  paresis. 

Diagnosis. — The  form  of  meningitis  of  the  convexity  presents  so 
many  symptoms  that  are  common  to  other  brain  diseases,  that  the  matter 
of  diagnosis  is  often  very  difficult,  and  it  is  impossible  at  times  to  deter- 

1  Brain,  Oct.  1879,  p.  314. 


CHRONIC    CEREBRAL    MENINGITIS.  75 

mine  the  nature  of  the  patient's  disease  until  after  death.  Meningitis  of 
the  base,  however,  is  much  more  easily  diagnosed.  There  are  nearly 
always  ophthalmoscoj)ic  appearances,  which  is  rarely  the  case  in  the  other 
form  of  disease  and  some  one  or  all  of  the  cranial  nerves  are  paralyzed. 
The  symptoms  of  tumor  may  counterfeit  those  of  chronic  basilar  menin- 
gitis, but  perhaps  are  more  severe.  If  the  disease  be  of  a  syphilitic 
character,  the  question  of  diagnosis  is  a  puzzling  one ;  for  in  some 
respects  a  condition  which  favors  the  formation  of  syphilitic  tumor  and 
chronic  meningitis  is  the  same,  and  occasionally  these  two  diseases  are 
found  to  coexist. 

Prognosis. — Should  the  disease  be  syphilitic,  the  prognosis  is  favora- 
ble, unless  the  trouble  be  of  long  standing,  but,  if  it  be  the  result  of  injury, 
recovery  is  less  likely  to  take  place ;  should  it  follow  the  acute  exanthe- 
matous  fevers,  there  is  very  little  hope. 

Treatment. — Our  main  reliance  is  in  the  free  use  of  large  doses  of 
iodide  of  potassium,  or  in  the  employment  of  mercurials.  Active  counter- 
irritation  and  the  use  of  blisters  and  cauterization  may  afford  a  great  deal 
of  relief.  A  saturated  solution  of  the  iodide  of  potassium  may  be  ordered, 
and  the  patient  should  be  directed  to  begin  with  a  dose  of  ten  drops  three 
times  a  day,  and  gradually  increase  one  drop  with  each  dose  until  he 
takes  a  hundred  drops  or  more  during  the  twenty -four  hours. 


CHAPTER    II. 

DISEASES  OF  THE  CEREBRUM  AND  CEREBELLUM. 

SYMPTOMATIC  CEREBRAL  HYPEREMIA. 

Synonyms. — Cerebral  Congestion,  temporary  Cerebral  Congestion 
(A  lid  ml).     Hyperemie  Cerebrale  (Fr.).    Hyperiimie  des  Gebirns  (Ger.') 

Definition. — A  condition  characterized  by  an  abnormal  increase  in 
the  amount  of  blood  contained  in  the  cerebral  vessels  and  expressed  by 
symptoms  which  indicate  pressure  and  irritation  of  the  cerebral  nerve 
cells;  such  increase  in  blood  pressure  being  the  result  usually  of  general 
bodily  disease. 

Until  a  few  years  ago  this  trouble  was  considered  as  a  form  of  organic 
cerebral  disease,  at  least  as  a  part  of  a  morbid  process  terminating  inevit- 
ably in  softening  or  cerebral  hemorrhage.  Such  is  the  treatment  of  the 
subject  by  ^Andral,  ^Durand-Fardel, ''Calmiel  and  many  others.  Not- 
withstanding the  fact  that  Andral  describes  a  "  temporary  cerebral  hy- 
peremia," the  condition  never  received  any  extended  notice  until  fifteen 
or  twenty  years  ago.  ^Schmidt  describes  functional  hyperemia  and  anae- 
mia in  his  Compendium  ;  and  Jaccord,  Hammond  and  others  since  have 
clearly  established  a  form  of  cerebral  hypersemia  which  has  not  of  neces- 
sity any  connection  with  graver  cerebral  troubles. 

Before  entering  into  the  discussion  of  the  affection,  I  desire  to  state  that 
in  very  few  cases  do  I  consider  cerebral  hypersemia  to  be  a  distinct  cerebra 
disease,  but  rather  one  form  of  expression  of  some  general  condition,  and, 
for  this  reason,  I  prefer  to  use  the  designation  symptomatic.  The  apo- 
plectiform variety  originally  described  by  Andral,  and  many  years  after- 
wards by  Trousseau,  is  without  doubt  a  result  of  vascular  rupture,  and 
should  be  classed  under  "  cerebral  hemorrhage." 

Symptomatic  cerebral  hypersemia  includes  those  varieties  of  increased 
cerebral  blood  pressure  dependent  usually  upon  diseases  of  the  heart,  liver 
or  kidneys ;  such,  for  instance,  as  the  symptom  described  by  Bright  as 
"  the  effect  of  cerebral  blood  pressure  with  venous  turgpscence,"  either  func- 
tional or  organic,  or  upon  any  condition  which  impedes  the  return  of 
venous  blood  from  the  head. 

^Clinique  Medicale. 

^Traites  des  Maladies-Tnffammatoires  du  Cervean,  tome  1.  Paris,  1859. 
•''Traite  du  Rimollis«ement  dii  Cerveaii,  Paris,  1843,  p.  153. 
*  Compendium  der  Nervenkrankheiten,  Leipzig,  1869. 
76 


SYMPTOMATIC    CEREBRAL    HYPEREMIA.  77 

Two  forms  of  cerebral  hypersemia  have  been  recognized  by  the  majority  of 
modern  medical  writers,  one  of  them  which  is  active  and  connected  with  for- 
cible arterial  fluxion,  and  the  other  passive,  and  the  result  of  some  impedi- 
ment to  the  venous  return.  I  prefer  to  adopt  the  terms  sthenic  and  asthe- 
nic, as  these  expressions  denote  pathological  conditions  much  more  appro- 
priately than  do  those  in  common  use.  Either  may  exist  in  a  modified 
degree  as  physiological  states,  and  it  is  often  difficult  to  make  the  dis- 
tinction between  a  normal  process  and  a  diseased  condition  ;  but  when 
the  cerebral  fulness  is  constant  or  increased  to  a  serious  extent,  we 
may  safely  judge  the  condition  to  be  pathological.  The  division  of  the 
disease  expressed  by  the  terms  I  have  just  mentioned,  though  adopted 
by  most  of  the  authorities  on  nervous  diseases,  is  for  some  reasons  unne- 
cessary. 

Both  varieties  may  lead  to  accidents  symptomatized  by  attacks  of 
coma,  accessions  of  convulsion,  a  low  grade  of  paralysis,  mental  excite- 
ment, and  other  serious  results.  These  differ  only  in  their  manner  of 
appearance.  In  one,  they  are  early  and  sthenic  expressions,  and  are  pro- 
duced by  rapidly  exerted  and  violent  force ;  and  in  the  other  their  ad- 
vent is  more  slow,  as  they  appear  to  be  produced  by  a  sluggish  force  or 
tardy  impairment  of  cell  function,  though  sudden  accidents  which  embar- 
rass the  venous  return  may  make  their  appearance  as  immediately  as 
those  of  the  first  variety.  Stupor  is  more  decidedly  characteristic  of  the 
passive  or  asthenic  variety,  than  that  in  which  rapid  dynamic  arterial 
action  takes  place.  In  this,  the  second  variety,  there  seems  to  be  a  dila- 
tation of  the  small  vessels,  a  crowding  out  of  the  perivascular  fluid,  and 
consequent  pressure  of  the  distended  vessels  upon  the  hyaline  membrane 
next  to  the  cells,  thus  preventing  the  removal  of  effete  material,  and 
consequently  impairing  their  normal  action. 

Symptoms. — The  symptoms  of  this  condition,  as  I  have  stated,  may 
vary  from  evidences  of  what  seems  to  be  but  healthy  physiological  func- 
tion to  those  which  are  unmistakably  grave  pathological  conditions;  from 
simple  throbbing  of  the  temporal  vessels  and  flushing  of  the  face,  to  coma, 
convulsions,  or  mania. 

Generally  the  symptoms  are  not  serious,  and  out  of  the  many  cases  I 
have  seen  (and,  by  the  way,  a  large  number  of  these  mild  cases  are  met 
with  in  private  practice)  they  are  of  a  type  which  may  be  recognized  at 
once.  The  patient  calls  attention  to  the  following  troubles  :  A  sense  of 
head- fulness  with  throbbing  of  the  temporal  arteries.  He  may  inform  us 
that  his  "  head  seems  to  be  of  unnatural  size  and  great  weight ;  that  he 
feels  as  if  the  skin  covering  the  head  is  much  too  tight."  He  complains 
of  tinnitus  aurium,  and  is  troubled  by  subjective  sounds  which  he 
compares  to  the  buzzing  of  bees,  the  ringing  of  bells,  and  the  rushing 
of  waters. 

There  seems  to  be  an  extraordinary  acuteness  of  all  the  senses.  He 
may  inform  us  that  there  are  bright  specks  or  motes  which  flit  across  the 
field  of  vision,  and  may  say  that  bright  light  is  painful,  complaining  of 
his  inability  to  read  fine  print,  because  the  letters  seem  to  dance  upon  the 


78  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM, 

page,  and  the  words  appear  hazy  and  blurred.  Diplopia  and  other  visual 
troubles  may  annoy  him.  Sharp  noises,  harsh  voices,  and  monotonous 
sounds  seem  to  produce  distress  and  discomfort.  His  head  is  hot ;  and 
Rosenthal  has  found  that  the  thermometer  introduced  into  the  external 
auditory  meatus  recorded  a  rise  in  temperature.  He  may  have  hallu- 
cinations, but  is  generally  able  to  appreciate  their  unsubstantial  charac- 
ter. He  arises  in  the  morning  unrefreshed  and  uncomfortable,  complain- 
ing of  muscular  weariness,  but  feels  better  towards  the  middle  of  the  day. 
After  his  dinner,  particularly  if  it  has  been  a  hearty  one,  the  cerebral 
condition  is  aggravated.  At  night  he  finds  it  impossible  to  sleep,  and  he 
tosses  to  and  fro,  his  head  being  hot  and  his  extremities  cold.  The  mind 
of  the  patient  is  preternaturally  active,  and  his  brain  seems  filled  with 
excited  fancies  and  troubled  thoughts — and  at  last  he  sleeps.  This  sleep, 
however,  is  not  sound ;  dreams  of  all  kinds,  or  nightmare,  keep  him  in  a 
state  of  wretched  semi-consciousness  till  the  morning  comes  to  find  him 
utterly  used  up.  With  the  patient,  mental  exertion  is  irksome,  and  study 
or  concentration  is  disagreeable  or  impossible.  There  is  headache  or  im- 
paired memory,  thickness  of  speech,  and  various  difficulties  of  articula- 
tion. He  may  substitute  one  word  for  another,  even  though  it  be  one  in 
common  use  and  exceedingly  familiar. 

The  emotions  are  generally  disturbed  and  altered.  Irritability,  over- 
sensitiveness,  nervous  excitement,  and  morbid  exhilaration  of  spirits  may 
make  his  conduct  strange  and  unnatural  to  those  about  him;  while  slight 
things  seem  to  disturb  and  harass  him.  The  attentions  of  friends,  though 
they  may  be  of  the  most  considerate  nature,  are  met  with  explosions  of 
temper,  and  the  patient  avoids  them  and  prefers  solitude.  In  such  indi- 
viduals in  whom  the  condition  has  existed  for  some  time,  this  mental 
chano-e  is  striking.  They  are  suspicious  of  their  wives  and  best  friends, 
and  all  sorts  of  eccentricities  are  indulged  in.  There  may  be  a  species 
of  hysteria  which  prompts  the  individual  to  commit  suicide,  when  he  has 
no  intention  of  doing  anything  of  the  kind.  He  may  worry  his  friends  by 
his  capricious  behaviour,  and  succeed  in  making  every  one  about  him 
miserable.  Sometimes  he  takes  violent  exercise  until  completely  ex- 
hausted, when  wearied  Nature  asserts  herself  and  sleep  brings  temporary 
relief. 

During  the  progress  of  the  disease,  cutaneous  numbness  or  twitching  of 
some  of  the  muscles,  or  even  paralysis,  gives  the  condition  a  serious  char- 
acter. The  appearance  of  the  patient  is  decidedly  striking,  and  not  to  be 
mistaken.  The  face  is  red,  the  cheeks  puffed  and  swollen,  the  eyes  promi- 
nent, watery,  and  injected,  and  the  conjunctivae  quite  red.  He  is  anxious 
and  excited,  or,  on  the  other  hand,  stupid.  The  sleepy  expression  is  one 
of  the  most  valuable  objective  symptoms.  Occasionally,  in  the  course  of 
the  disease,  there  is  bleeding  from  the  nose,  which  may  temporarily  re- 
lieve the  patient.  The  hands  and  feet  are  usually  blue  and  cold,  and  so 
remain.  After  a  variable  period,  during  which  the  patient  has  presented 
a  number  of  these  symptoms,  he  may  suddenly,  after  a  hearty  meal,  or 
violent  exertion  or  some  other  exciting  cause,  suffer  an  incomplete  loss  of 


SYMPTOMATIC    CEREBRAL    HYPEREMIA.  79 

consciousness/  wlncli  is  generally  of  short  duration,  and  from  which  he 
can  be  aroused  in  a  few  minutes.  When  spoken  to  he  seems  bewildered 
and  conl'used,  and  takes  but  little  notice  of  what  is  going  on  about  him. 
There  seems  to  be  incomplete  loss  of  muscular  power,  more  confined  to 
one  side  than  to  the  other,  and  he  is  able  when  less  dazed  to  make  simple 
voluntary  movements.  He  seems  to  be  annoyed  by  any  bright  light  that 
may  be  let  into  the  room.  His  pupils  are  contracted  usually,  and  respi- 
ration is  labored,  while  circulation  is  uneven,  there  being  an  irreo-ular 
pulse.  At  first  the  heart's  action  seems  to  stop  altogether,  but  subse- 
quently it  becomes  quite  energetic,  and  the  pulse  is  bounding  and  full. 
Kthe  attack  be  due  to  passive  congestion,  there  may  be  a  dilatation  of 
the  pupils,  and  the  bloating  and  puffing  of  the  face  and  fulness  of  the 
lips  will  be  much  more  noticeable  than  when  it  is  the  result  of  the  sthenic 
variety.  During  its  continuance  there  is  neither  rigidity  of  the  muscles 
nor  stertorous  breathing.  The  recovery  is  generally  rapid,  and  after  the 
attack  there  may  may  be  some  epistaxis  and  slight  mental  excitement. 

A  form,  which  certain  writers  have  called  maniacal,  may  and  does 
often  occur  without  any  of  the  characteristic  symptoms  of  increased  cere- 
bral blood  pressure  that  I  have  described.  It  is  the  form  Milner  Fother- 
gill  has  so  admirably  described,'^  and  characterizes  usually  the  pathologi- 
cal condition,  in  which  the  nervous  tissues  attract  an  abnormal  amount 
of  blood  to  themselves.  This  variety  is  not  necessarily  connected  with 
vascular  excitement,  suffusion  of  the  face,  etc.  It  results  commonly  from 
protracted  intellectual  labor  and  direct  excitement,  and  the  patients  may 
be  pale  and  bright-eyed,  and  active  in  all  their  movements.  They  are 
"  high-strung,"  restless,  and  remarkably  irritable,  and  at  the  same  time 
are  loquacious  and  voluble.  Their  thoughts  and  fancies  seem  crowded 
together,  and  are  evidently  originated  much  more  rapidly  than  they  can 
be  expressed.  "  Sometimes  their  ideas  seem  to  settle  themselves  around 
some  prominent  leading  thought,  the  centre-piece  of  the  rotatory  chaos, 
while  at  other  times  there  is  mental  excitement,  with  great  volubility,  on 
no  subject  in  particular."  The  condition  is  one  of  exaltation,  and  there 
is  a  restlessness  which  is  characteristic. 

There  is  rarely  any  forcible  heart  action,  the  pulse  being  normal,  or,  if 
changed  at  all,  is  simply  small  and  irritable.  This  condition  does  not 
seem  to  be  confined  to  any  particular  age,  though  in  old  people  cerebral 
congestion  is  disposed  to  take  this  character.  The  mental  features  may 
be  those  of  ordinary  acute  mania,  and  all  the  phases  of  psychical  disturb- 
ance may  be  expressed  at  some  time  or  other.  Suicidal  tendencies  are 
sometimes  present.  A  case  of  this  kind  is  reported,  where  the  individual, 
during  an  attack  of  congestive  mania,  cut  his  throat.  The  loss  of  blood 
relieved  the  cerebral  fulness,  and  his  reason  returned,  but  too  late  to 
avert  the  consequences  of  the  act.  This  condition  is  one  of  rapid  produc- 
tion, and  under  prompt  treatment  may  disappear.     Embarrassment  of 


^Thesie  symptoms  are,  without  doubt,  due  to  small  hemorrhages. 
^West  Riding  Eeports,  art.  Cerebral  Hypersemia,  vol.  v.  p.  171. 


80  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

speech  may  vary  from  simple  awkwardness  of  articulation  to  decided 
aphasia.'  The  difficulty  is  rarely  a  serious  or  lasting  one,  and  is  relieved 
by  appropriate  treatment. 

As  I  have  before  remarked,  the  second  variety  is  more  apt  to  be  asso- 
ciated with  deep  stupor,  and  recovery  is  less  certain  and  rapid. 

There  may,  indeed,  be  a  form  in  which  profound  stupor,  stertor,  and 
full  hard  pulse  are  present,  and  which  is  almost  always  fatal.  This 
follows  profound  narcosis  by  alcohol  or  opium,  and  the  death  of  the  indi- 
vidual is  preceded  by  involuntary  discharge  of  feces  and  urine,  and 
there  is  complete  loss  of  voluntary  muscular  power. 

Before  concluding  the  description  of  the  condition,  it  may  be  well  to 
call  attention  to  a  form  which  is  chiefly  confined  to  early  life,  and  occurs 
in  the  course  of  other  diseases,  or  it  may  exist  uncomplicated.  In  many 
respects  it  resembles  meningitis.  It  is  characterized  by  elevation  of  tem- 
perature and  other  febrile  symptoms,  among  them  vomiting,  flushed  face, 
headache,  broken  sleep,  twitching  of  the  limbs,  constipation,  and  wander- 
ing delirium.  Convulsions  occasionally  occur,  and  the  attack  ends  in 
deep  sleep.  Recovery  is  the  rule,  although  the  young  brain  is  so  delicate 
and  the  violence  of  congestive  disease  so  excessive,  that  a  passive  condi- 
tion may  take  the  place  of,  and  remain  after  the  acute  condition,  and 
death  may  ultimately  follow.  Epilepsy  not  rarely  originates  in  this  way. 
It  cannot  be  doubted  that  mental  worry  causes  cerebral  congestion,  and 
therefore  accelerated  action  of  the  heart  gives  rise  to  contracted  kid- 
ney and  urajmic  symptoms. 

Causes. — Calmeil  ^  and  others  consider  that  men  are  far  more  subject 
to  cei'ebral  hypertemia  than  women,  and  I  think  clinical  experience  fully 
supports  their  views.  Some  occupations  and  vices  of  men  are  peculiarly 
apt  to  lead  to  disordered  states  of  the  circulation,  while  women,  as  it  will 
be  seen,  are  not  affected  nearly  so  often  as  the  other  sex,  and  generally 
suffer  only  at  the  menstrual  periods  or  when  there  is  a  retarded  flux. 
Andral  calls  attention  to  the  symptoms  complained  of  by  women  just 
before  the  time  of  the  menstrual  period — these  are  vertigo,  flushing  of 
the  face,  troubled  respiration,  flashes  before  the  eyes,  and  other  evidences 
■which  point  to  congestion  of  the  brain.  When  the  menses  are  irregular 
or  suppressed  these  symptoms  are  more  intense,  but  are  promptly  relieved 
by  re-establishment  of  the  flow.  He  relates  the  case  of  a  man  who 
every  summer  suflTered  from  an  acute  train  of  symptoms  indicative  of 
softening,  which  subsided  after  he  had  had  an  hemorrhage  from  the  bowels. 
There  was  no  history  of  hemorrhoids.  It  is  not  confined  to  any  age,  but 
is  commonly  a  condition  of  middle  life,  though  special  causes  may  influ- 
ence its  origin  at  other  periods. 

As  to  the  etiological  bearing  of  climate  and  temperature,  there  has  been 
much  discussion.     As  far  back  as  the  time  of  Hippocrates^  we  have  been 

^  Tliis  grave  form  is  probaWy  due  to  some  lesion. 
2  Maladies  inflainmatoire  du  Cerveau. 
^  Aphor.,  Lect.  iii.  16,  23. 


I 


SYMPTOMATIC    CEREBRAL    HYPEREMIA.  81 

told  tliat  it  is  a  condition  produced  or  aggravated  by  low  temperature,  in 
whicli  opinion  he  is  sustained  by  Aretseus/  Cheyne  and  others  consider 
that  extreme  heat  favors  this  morbid  state,  and  Andral  contends  that  the 
greater  number  of  cases  occur  in  cold  weather. 

As  far  as  my  own  experience  is  concerned,  I  have  found,  that  either 
extreme  heat,  or  cold,  may  develop  the  disease,  but  the  greatest  number  of 
my  cases  have  arisen  from  exposure  to  the  direct  rays  of  the  sun,  or  have 
been  among  men  whose  avocation  led  them  to  pass  their  time  in  hot  places. 
Bakers,  sugar- refiners,  furnace-men,  glass-blowers,  etc.  etc,  are  often 
affected,  and  it  is  hard  to  say  whether  these  people  or  those  who  overuse 
their  brains,  form  the  largest  number.  I  give  below  a  table  which  details 
the  occupation  of  160  of  my  patients. 

One  Hundred  and  Sixty  Cases  of  Cerebral  Hypercemia — Occupation. 

Bartenders,  or  Lic[uor  Dealers  .  18  Lawyers 16 

Bakers 15  Masicians 2 

Blacksmiths 19  Merchants 15 

Carpenters 3  Paintei-s 2 

Carpet-cleaners 1   ■      Physicians 6 

Foundrymen 6  Printers, 2 

Harness-makers 2  Reporters    ...........    4 

Jewellers 2  Tailors 1 

'    Seamstresses 5  Teachers 13 

Laundresses 3  Miscellaneous 17 


Laborers 8 


160 


By  this  table  it  will  be  seen  that  64  were  individuals  whose  pursuits 
subjected  them  to  exposure  to  heat,  and  54  were  among  persons  who  were 
hard  students,  worried  business  men,  and  the  like. 

Immediately  after  the  heated  term  of  1872  I  saw  many  patients  whose 
cerebral  condition  was  produced  by  the  great  heat;  but  the  disease 
may  be  due  in  many  instances  to  exposure  and  cold,  or  is  at  least  greatly 
aggravated  by  low  temperature.  Perhaps  a  reason  for  this  may  be  that 
in  cold  weather  the  cutaneous  circulation  is  not  so  active  as  during  the 
warmer  season,  when  the  sudorific  apparatus  requires  a  free  capillary 
circulation,  and  for  this  reason  there  is  a  determination  of  blood  to  the 
surface.  In  cases  of  sunstroke,  as  we  know,  the  skin  is  generally  parched 
and  dry. 

As  to  predisposing  causes  we  may  enumerate  them  as  follows :  The 
organization  of  the  individual,  the  existence  of  other  disease,  his  habits 
etc.  Two  classes  of  individuals  may  be  the  subjects  of  cerebral  hypersemia. 
— those  of  the  thick-set  plethoric  habit,  which  Reynolds  calls  the  "  lax- 
fibred  constitution,"  and  those  who  are  spare,  well-knit,  and  of  nervous 
temperament.  These  latter  individuals  have  generally  hard,  rigid  arteries, 
are  past  middle  age,  and  are  usually  brain-workers. 

In  those  individuals  who  possess  a  well-developed  arterial  system,  but 

^  Aretseus  de  Signi  et  Caus.  morbd.  d.  lib.  1,  c.  7. 


82  DISEASES    OF    THE    CEREBRUM    AXD    CEREBELLUM, 

such  configuration  of  the  neck  and  head  as  to  prevent  venous  return,  there 
is  a  tendency  to  cerebral  fulness.  There  are  several  morbid  conditions 
which  markedly  influence  the  development  of  this  state — malaria,  renal 
and  cardiac  diseases,  and  syphilis  being  among  the  number.  In  patients 
with  enlarged  and  diseased  kidneys  which  are  unable  to  excrete  the  effete 
nitrogenous  waste  from  the  blood,  it  remains  in  the  circulation,  increasing 
blood  pressure,  and  necessitating  excessive  activity  and  rapidity  of  heart 
action.  Hypertrophy  of  that  organ  is  a  result,  and  the  walls  of  the  right 
ventricle  become  greatly  enlarged  ;  and  having  much  greater  force  than  it 
possesses  in  its  normal  condition,  it  forces  the  blood  with  great  energy  into 
the  cerebral  vessels,  and  as  a  result  there  is  produced  the  morbid  condition 
of  which  we  have  spoken.  Pulmonary  disease,  attended  by  diminished 
aerating  space,  sometimes  has  the  same  influence.  Gout  may  be  at  the 
origin  of  cerebral  hypersemia ;  and,  as  I  have  said,  malaria  very  often  plays 
a  very  important  part  in  the  etiology. 

Syphilis  I  have  found  to  have  much  to  do  with  cerebral  hypersemia.  In 
this  disease  this  condition  of  the  cerebral  ves^sels  is  not  uncommon  during 
the  secondary  and  tertiary  stages,  but  more  often  during  the  latter.  Four- 
nier  has  described  a  form  of  trouble  produced  by  syphilis  characterized 
by  head-fulness,  vertigo  and  attacks  of  unconsciousness  of  an  apoplectiform 
nature,  and  ^Chauvet  thinks  that  such  forms  are  but  precursors  of  an 
inflammatory  condition  of  the  cerebral  vessels,  and  that  it  is  followed  by 
narrowing  of  calibre  and  anaemia.  Mental  perturbation  and  hysteria 
seem  to  be  connected  with  these  forms. 

An  excessive  indulgence  in  alcohol,  immoderate  eating  and  drinking 
or  the  abuse  of  tobacco ;  continued  venery,  and  disregard  of  the  ordinary 
calls  of  nature,  are  all  predisposing,  and  some  of  them  exciting,  causes. 
Protracted  or  unnatural  intellectual  labor,  emotional  disturbance,  mental 
strain,  and  intense  excitement  of  various  kinds,  are  additional  causes  of 
great  importance. 

Intellectual  labor  at  night,  particularly  when  there  is  a  gas-light  above 
the  head  of  the  patient,  or  prolonged  business  worry,  not  rarely  favors 
the  determination  of  blood  to  the  brain.  Night  editors,  students,  and 
workers  by  artificial  light  are  subject  to  this  condition,  and  eye-strain 
from  these  occupations  is  a  powerful  factor  in  the  causation. 

Myopia  and  various  errors  of  refraction  and  accommodation  are  some- 
times at  the  origin  of  severe  headaches  of  the  congestive  variety.  Pro- 
longed grief,  especially  when  the  patient  neglects  his  bodily  comfort,  and 
passes  long  days  in  mourning,  eating  little,  and  gaining  no  sleep,  is  also 
a  cause.  The  acute  condition  is  not  rare  among  nurses  who  have  sat  up 
at  night ;  and  they,  as  well  as  other  night-workers,  are  very  apt  to  com- 
bat the  disposition  to  sleep  which  is  healthy,  by  stimulants,  coffee,  or 
other  agents,  and  after  a  short  period  a  disagreeable  state  of  congestion 
follows. 

'  These  de  CoTicour.i,  1880.  Influence  de  la  syphilis  sur  les  maladie  du  systenie 
nerveux.  p.  9. 


SYMPTOMATIC    CEREBRAL    HYPEREMIA.  83 

As  distinct  exciting  causes  I  may  mention  alcoholic  abuse — pressure 
made  upon  the  veins  of  the  neck  by  tight  collars  or  other  articles  of  dress 
— sudden  exertion  of  any  kind,  such  as  straining  at  stool,  or  during  child- 
birth, and  lifting  heavy  weights.  In  one  of  my  patients,  the  simple  act 
of  bending  over  to  button  his  shoe  was  sufficient  to  produce  an  alarming 
condition  of  the  cerebral  circulation.  In  some  persons  the  condition  is 
aggravated,  or  attacks  of  the  severer  kind  are  precipitated  by  a  visit  to 
the  theatre  or  some  crowded  place  of  amusement,  where  ventilation  is  bad 
and  the  room  heated  to  a  high  temperature. 

Pathology.^  —Almost  enough  has  been  said  to  explain  the  changes 
which  occur  during  the  development  of  a  morbid  state  of  intra-cranial 
circulation.  Fothergill  intelligently  divides  the  processes  which  may  in- 
duce this  condition  as  the  following:  1.  It  may  occur  as  a  vascular  form, 
with  increased  blood  pressure,  and  be  dependent  upon  extra-cranial  agen- 
cies. 2.  It  may  result  from  tissue  alterations,  in  which  the  blood  is  at- 
tracted to  the  brain,  or  from  toxic  agents,  when  the  two  former  modes 
are  combined. 

Through  the  cerebral  ventricular  connection  and  the  spaces  in  the 
arachnoid  we  have  reservoirs  for  accumulation  of  the  fluid,  when  the 
blood  pressure  is  diminished,  and  a  loose  and  capacious  receptacle  in  the 
spinal  arachnoid  sacs  for  containing  this  fluid  when  the  blood  pressure  is 
above  the  average,  so  that  the  balance  is  generally  preserved.  When  the 
harmonv  of  this  arrangement  is  disturbed,  we  may  expect  to  find  evi- 
dences of  such  inequality. 

JSTow  the  question  of  the  extent  to  which  the  brain  may  be  compressed 
without  injury,  is  one  which  I  think  will  bear  more  discussion  than  it  has 
hitherto  received.     IS^ot  only  are  the  present  means  for  experimentation 

'  By  far  the  most  important  and  interesting  part  of  the  study  of  brain  histology 
is  tiie  intricate  and  beautiful  arrangement  of  the  perivascular  space  discovered  by 
Robin*  and  His,  f  and  described  by  them  as  well  as  by  Bastian,  %  Fothergill,  and 
others.  His  demonstrates  the  existence  of  these  small  spaces  which  surrounded  the 
vesssels,  than  which  they  were  several  times  larger.  He  found  them  in  greater 
numbers  in  the  gray  substance,  and  thought  he  discovered  a  communication  between 
the  spaces  in  the  brain  and  cord  and  certain  lymph-ducts  in  the  pia  mater. 

The  office  of  these  canals  which  loosely  contain  the  vessels,  with  which  they  have 
no  attachment,  is  a  most  important  one ;  for,  notwithstanding  the  fact  that  the  force 
of  blood  (particularly  that  which  goes  to  the  cerebrum)  is  moderated  by  the  tortu- 
ous course  of  the  arteries  after  they  enter  the  cranium,  and  their  complete  subdivision 
when  they  are  distributed  over  the  pia  mater,  the  nervous  substance  would  be  little 
prepared  without  such  xin  arrangement  for  sudden  and  violent  accession  of  blood. 

This  space  or  cavity  about  all  of  the  vessels  enables  them  to  expand  to  a  great  ex- 
tent without  any  actual  pressure  being  made  upon  the  adjacent  delicate  tissues. 
When  such  a  determination  of  blood  occurs,  the  perivascular  fluid  is  driven  out  of 
the  nervous  substance  proper,  and  after  the  hypersemia  subsides,  returns  to  the  spaces 
about  the  vessels. 


*  Corapte  Rendu  de  la  Soc.  Biol.,  Paris   1855. 

t  Zeitschrift  fiir  Wiss.  Zoologie,  Band  15. 

X  Xotes  to  translation  of  His's  paper.  Journal  of  Anatomy,  vol.  1. 


84  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

inadequate,  but  there  are  certain  puzzling  questions  that  come  up  in  the 
most  unexpected  manner.  The  experiment  of  suspending  the  subject, 
constricting  the  vessels,  and  measuring  tlie  blood  pressure  by  instruments 
devised  for  the  purpose,  has  been  tried.  Dr.  Loring '  has  related  an  in- 
stance where  the  first  experimqnt  was  made,  and  I  shall  use  his  own  words : 
"  I  would  mention  that  a  patient  of  mine,  the  acrobat  known  as  the 
'  Cliampion  Fly  Walker,'  informed  me  that  in  walking  across  the  ceiling 
of  a  theatre,  head  downwards,  he  never  felt  the  slightest  disturbance  in 
his  vision,  though  the  feat  occupied  fifteen  or  twenty  minutes.  This 
would  go  to  show,  also,  that  position  did  not  have  so  marked  an  influence 
on  the  quantity  of  either  blood  or  serum  in  the  interior  of  the  head  as  is 
now  believed  to  be  the  case.  For  it  hardly  seems  possible  that  the  quan- 
tity of  blood  could  be  either  increased  or  diminished  to  any  considerable 
degree,  even  at  the  expense  of  the  other  fluids,  and  yet  allow  one  to  main- 
tain for  so  long  a  time  such  a  complete  control  over  the  faculties,  espe- 
cially that  of  co-ordination,  as  to  perform  so  dangerous  a  feat,  and  one 
winch  demanded  so  nice  an  application  of  the  senses.  Be  this  as  it  may, 
I  must  say  I  have  never  been  able  to  see  the  great  weight  of  Kellie's  and 
Burrows'  experiments  with  animals  which  were  killed  and  then  suspended 
by  the  head  or  heels,  as  the  case  might  be." 

When  an  individual  is  thus  suspended,  we  ai'e  furnished  Avith  all  the 
external  indications  of  cerebral  hypergemia — the  flushed  face,  prominent 
eyes,  etc. — but  consciousness  is  unimpaired,  and  is  not  lost  until  some 
time  has  elapsed.  This  question  is  of  interest,  for  it  suggests  the  idea  that 
perhaps  after  all  many  changes  in  cerebral  function  are  due  to  the 
shock  sustained  by  nerve-cells  by  the  sudden  accession  of  blood,  and  not 
so  much  to  the  mechanical  pressure  exerted.  -  In  a  very  carefully  pre- 
pared article  by  Cappie  in  "  Brain  "  upon  the  balance  of  pressure  within 
the  skull,  it  is  shown  that  the  atmospheric  pressure  is  exerted  upon  the 
veins  as  they  leave  the  various  openings  in  the  skull,  thus  opposing  the 
sudden  exit  of  blood.  He  also  alludes  to  the  interlacement  of  vessels  in 
the  pia  mater  and  the  process  of  compression  recurring  when  some  of 
these  vessels  become  distended.  It  is  not  difficult  to  realize  that  as  a 
rule  under  ordinary  circumstances  the  cerebral  blood  pressure  receives 
no  very  rude  modifications. 

As  to  the  value  of  other  methods  for  studying  the  state  of  the  cerebral 
circulation  by  gauges,  watch-glasses  luted  into  the  skull,  etc.,  I  am  rather 
sceptical.  The  cranial  cavity  is,  of  course,  a  closed  cavity,  and  the 
blood  supply  of  its  contents  is  modified  by  the  pi-essure  of  the  bony  wall. 
Any  perforation  must  admit  the  external  air,  and  the  intra-cranial  blood 
is  then  circulating  under  an  atmospheric  j^ressure,  and  I  am  strongly  con- 
vinced such  variations  as  have  been  described  are  not  those  that  take 
in  the  normal  state. 

I  have  said  sufficient  in  detailing  the  causes  of  cerebral  hyperremia  to 

^  Am.  Psycholog.  Journ.,  Nov.  1875. 
2  Brain,  Part  viii.  1879,  p.  373. 


SYMPTOMATIC  CEREBRAL    HYPEREMIA.  85 

explain  any  pathological  processes,  the  description  of  which  I  may  now 
pass  over. 

Morbid  Anatomy. — Upon  removing  the  calvarium  the  observer  of  a 
fatal  case  will  probably  meet  with  some  if  not  all  of  the  following  appear- 
ances Dura  mater  and  underlying  membranes  injected  and  pink,  or  opales- 
cent, and  sometimes  quite  free  from  moisture,  resembling  in  this  respect  a 
piece  of  damp  sheepskin.  The  sinuses  may  be  filled  with  dark  blood, 
and  the  surface  of  the  brain  flattened  and  of  a  deeper  color  than  normal. 
The  convolutions  may  be  flattened  and  pressed  down  so  that  the  sulci 
are  defined  in  sharp  lines,  the  inner  surface  of  the  convokitions  being 
pressed  together.  The  surface  of  the  brain,  as  I  have  said,  is  dark,  and 
if  the  pia  mater  is  torn  ofl"  fluid  blood  may  escape  from  the  separated 
vessels.  Upon  making  sections  in  a  transverse  plane  the  observer  will 
be  sometimes  struck  by  the  appearance  of  a  pinkish  blush,  visible  in 
spots,  which  is  due  to  staining  by  hsematoidin.  This  appearance,  alluded 
to  by  Fox  ^  has  been  compared  to  spots  of  red  sand  dusted  on  the  surface. 
The  corpora  striata  are  of  a  very  deep  red  or  even  violet  color,  and  the 
white  matter  contains  small  puncta  which  are  red  or  dark  purple.  The 
vessels  are  generally  enlarged,  tortuous,  and  filled  with  quite  dark  blood. 
CalmeiP  has  presented  the  records  of  autopsies  in  a  number  of  cases  of 
temporary  duration.  He  found  "  in  three  cases  that  the  cranial  bones 
were  notably  injected ;  in  three  the  vessels  of  the  dura  mater  were  con- 
gested ;  in  one  case  there  was  fibrinous  coagulation  in  the  longitudinal 
sinus;  in  one  the  internal  surface  of  the  dura  mater  was  furrowed  by 
capillary  arborizations ;  in  two  the  cavity  of  the  arachnoid  contained 
liquid  blood  and  bloody  humidity ;  in  four  the  cerebral  pia  mater  was 
generally  congested ;  in  three  cases  it  was  reddened  by  extravasated 
blood ;  in  one  the  pia  mater  adhered  in  spots  to  the  subjacent  convolu- 
tions ;  in  one  these  convolutions  on  the  right  side  were  swollen ;  in  lour 
the  cortical  substance  of  the  brain  was  generally  injected  and  more  or 
less  colored  by  hsematosin,"  etc.,  etc.  We  therefore  must  arrive  at  the 
conclusion  that  there  is  nothing  remarkably  significant  in  regard  to  the 
seat  of  the  congestion  or  its  form.  The  violence  of  the  symptoms  will,  of 
course,  be  proportionate  to  the  extent  of  hypersemia,  though  this  is  not 
always  the  rule ;  and  I  have  seen  cases,  and  I  think  others  also  have,  in 
which  profound  coma  and  sjDeedy  death  were  preceded  by  unmistakable 
symptoms  of  hypersemia,  such  as  contraction  of  the  pupils,  etc.,  and  after 
death  very  slight  evidences  of  congestion  were  perceptible.  Microscopical 
examination  reveals  in  old  cases  a  condition  which  has  been  called  by 
various  writers  "  I'Etat  crible.  This  consists  of  a  peculiar  spongy,  worm- 
eaten  appearance,  Arndt  says  that  when  these  lymph-spaces  are  dilated 
they  are  filled  with  effete  material  from  the  brain  resembling  amyloid 
substance  or  leucin,  called  by  him  hyaline.  The  perivascular  spaces  are 
very  large,  and  openings  of  some  size  are  found  at  points  where  vessels 

^  Pathological  Anatomy  of  Nervous  Centres,  p.  55. 
^Quoted^by  Fox,  p.  56. 


86 


DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 


have  beeu  cut  across.  These  are  due  to  the  abnormal  pressure  made  by 
the  distended  vessel  and  the  de-truction  of  adjacent  nervous  tissue.  Cal- 
meil,  Van  der  Kolk,  Duraud-Fardel,  and  1  ;tely  Arndt/  have  accounted 
for  them  as  the  result  of  oedema  of  the  perivascular  space.  This  appear- 
ance is  a  constant  one  in  all  brains  where  there  has  been  continued 
hyperemia,  and  especially  in  the  brains  of  drunkards.    The  bloodvessels, 

Fig.  13. 


■^ 


Distended  rerivaseular  Spaces,  with  Atrophy.     (Fothergill.) 

when  not  destroyed,  w'ill  be  found  to  be  tortuous  and  varicose,  and  coated 
oftentimes  by  a  granular  shining  deposit.  The  pia  mater  is  thickened, 
and  its  vessels  present  the  appearance  just  described  perhajDs  better  than 
any  other  tissue. 

Diagnosis. — The  condition  in  its  early  stages  may  be  mistaken  for 
the  opposite  state,  cerebral  anicmia ;  in  fact,  the  diagnosis  is  always  full 
of  difficulties. 

An  inspection  of  the  following  table  may,  however,  furnish  us  with 
hints  so  that  we  may  be  enabled  to  separate  cerebral  congestion  from 
cerebral  ansemia.  It  will  be  observed  that  some  of  the  symptoms  are 
closely  allied. 


CEREBRAL  CONGESTIOX. 

Headache  (eenerally  difFused). 

Noises  in  the  ears,  generally  "  rum- 
bling,'' or  singing. 

ilental  disturbance — loss  of  memory, 
hallucination. 

Pupils  contracted. 

No  heart  sounds,  except  perhaps  those 
of  insufficiency.     Pulse  full. 

Urine  not  increased,  generally  con- 
tains urates  and  phosphates. 


CEREBRAL  ANiEMIA. 

Headache  (chiefly  vertical). 

Noises  in  the  ears  (generally  sharp  or 
short). 

Mental  disturbance  —  incapacity  for 
mental  work. 

Pupils  dilated. 

Pulse  irritable,  aortic  murmurs,  sphyg- 
mograpliic  tracing  almost  straight. 

Urine  passed  in  large  quantities,  is 
clear  and  limpid. 


^  Virchow's  Archiv.  Ixiii.  p.  24. 


SYMPTOMATIC    CEEEBEAL    HYPEEJEMIA.  87 

In  the  apoplectic,  convulsive,  and  paralytic  forms  there  is  little  danger 
of  making  a  mistake. 

These  phenomena  are  sometimes  liable  to  be  mistaken  for  meningeal  or 
cerebral  hemorrhages,  cerebral  embolism  or  thrombosis,  epilepsy,  ursemic 
coma,  etc. 

The  apoplectic  variety  may  be  confused  with  cerebral  or  meningeal 
hemorrhage.  When  we  bear  in  mind  that  in  the  former  there  is  generally 
almost  transitory  loss  of  consciousness  and  motor  power,  that  hemiplegia 
is  not  always  present,  and  that  marked  stertor  is  rarely  found,  there  is  no 
room  for  a  mistake  in  diagnosis. 

The  other  varieties  of  cerebral  trouble,  namely,  embolism  and  throm- 
bosis, may  be  disposed  of  by  calling  to  mind  the  sudden  appearance  of 
symptoms  in  the  former ;  its  association  with  cardiac  vegetations,  and  its 
permanent  after-effects. 

A  case  of  this  kind  presents  itself  to  my  mind.  A  gentleman,  brought 
to  me  by  Dr.  Asch,  of  New  York,  had  been  told  by  some  friend  that  his 
nervous  symptoms  were  due  to  embolism.  They  were  these:  Three 
months  before,  while  sitting  in  his  studio,  he  lost  consciousness,  and  fell 
over  upon  an  unfinished  picture.  He  was  conscious  of  his  condition,  but 
could  not  help  himself.  The  room  became  dark,  and  he  "  saw  spots  be- 
fore his  eyes."  He  recovered  himself  in  a  few  minutes,  and  resumed  his 
work.  A  week  ago  a  similar  attack  occurred  as  he  was  crossing  the 
street,  but  he  was  unable  to  rise  from  the  mud  before  assistance  came. 
He  had  been  worried  by  his  business,  had  worked  very  hard,  and  had 
kept  irregular  hours.  There  was  no  aural  disease.  On  neither  occa- 
sion did  the  attack  occur  after  a  hearty  meal.  He  had  no  heart  symp- 
toms at  all.  After  each  attack  he  recovered  when  he  took  the  needed 
rest,  and  then  saw  no  evidence  of  permanent  trouble.  The  suddenness 
of  his  attack  suggested  embolism,  but  as  no  paralysis  nor  aphasia  fol- 
lowed, and  no  after-symptoms  remained,  it  seemed  out  of  the  question 
to  consider  this  his  disease.  I  made  the  diagnosis  of  local  cerebral  hyper- 
semia. 

With  embolism  there  is  also  generally  pallor  of  the  face,  and  absence 
of  vascular  excitement. 

Thrombosis  is  a  disease  of  slow  and  steady  progress,  with  well-marked 
symptoms,  and  finally  decided  hemiplegia.  Aphasia  is  also  a  character- 
istic accompaniment  of  thrombosis  as  well  as  embolism. 

Cerebral  softening  can  hardly  be  mistaken  for  the  disease  under  con- 
sideration, because  the  former  is  nearly  always  preceded  by  partial  cere- 
bral ansemia,  or  else  some  distinctly  inflammatory  trouble.  In  cerebral 
softening  there  is  usually  local  pain.  Convulsive  movements,  paralysis, 
and  other  decided  indications  mark  the  course  of  the  softening. 

UrEemic  coma  may  be  distinguished  by  its  deep  character,  and  usually 
by  an  examination  of  the  patient's  urine. 

The  epileptic  attacks  of  cerebral  congestion  resemble  those  of  true 
epilepsy  very  closely,  and  in  many  cases  we  must  not  be  too  positive. 
There  is,  however,  rarely  any  disposition  to  sleep,  and  the  attacks  are 


00  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

generally  preceded  by  some  excitement,  and  are  not  ushered  in  by  the 
cry. 

Prognosis. — The  lighter  forms  of  this  morbid  condition  are  usually 
amenable  to  treatment,  at  least  this  has  been  my  own  experience.  Of 
course  we  must  be  governed  by  the  duration  of  the  disease,  the  existence 
of  other  affections  of  an  organic  nature,  and  the  age  of  our  patient.  If 
he  be  over  fifty  his  chances  of  ultimate  recovery  are  bad,  but  if  he  has 
not  passed  middle  life,  and  the  condition  is  directly  dependent  upon  some 
exciting  cause  that  can  be  easily  removed,  we  may  express  ourselves 
more  cheerfully.  The  existence  of  calcareous  vessels  is  not  an  agreeable 
circumstance,  nor  the'  fact  that  he  has  had  previous  attacks  of  an  apo- 
plectic or  paralytic  nature.  Perhaps  the  most  grave  prognosis  is  at- 
tached to  the  maniacal  form  in  which  the  delirium  is  not  violent  nor 
noisy,  but  incessant  and  muttering,  and  in  which  there  is  a  restlessness  and 
desire  for  constant  muscular  exertion.  The  great  danger  seems  to  be  in 
the  continuance  of  the  hyperremic  condition,  and  the  possibility  of  its 
termination  in  cerebral  hemorrhage,  meningitis,  cerebritis,  or  other  or- 
ganic affections.  With  a  hypertrophied  ventricle  and  renal  disease  the 
patient  has  little  to  expect  in  the  way  of  lasting  relief,  and  we  must  always 
give  in  such  cases  a  very  guarded  prognosis. 

Treatment. — Of  course,  the  first  indication,  after  inquiry  into  the 
patient's  habits  and  mode  of  life,  is  to  discover  and  remove  the  predispos- 
ing and  exciting  causes  if  possible.  The  next  is  to  diminish  blood  pressure, 
and  restore  the  lost  equilibrium  of  the  intracranial  blood  pressure  both 
by  local  and  general  treatment. 

In  the  majority  of  cases,  the  most  simple  treatment,  with  attention  paid 
to  the  patient's  bad  habits,  will  generally  remove  the  condition.  Absti- 
nence from  alcohol  in  some  cases,  attention  to  the  bowels,  and  the  precau- 
tion of  keeping  the  head  cool  and  the  neck  unconfined,  are  the  first  obser- 
vances to  be  followed  by  the  patient. 

If  the  condition  be  continued,  or  not  relieved  by  these  means,  we  may 
make  use  of  several  remedies,  among  them  the  bromides,  ergot,  and 
hydrobromic  acid.  The  bromides,  which  were,  I  believe,  first  used  for  this 
purpose  by  Laycock,  Clifford  Albutt,  and  Drummond,  promptly  effect  a 
diminution  in  arterial  tension  and  cerebral  blood  pressure.  Max  Schuler 
is  of  the  opinion  that  they  contract  the  small  vessels,  while  Nothnagle 
thinks  their  chief  action  is  upon  the  nerve  cells.     The  bromide  of  sodium 

1  consider  the  most  potent  of  these  salts,  and  in  doses  of  twenty  grains, 
three  times  a  day,  we  may  expect  the  best  results.  It  is  well  to  combine 
it  with  some  cardiac  sedative  when  there  is  tumultuous  heart  action,  or 
with  some  heart  tonic  when  there  is  a  suspicion  that  the  heart  impulse  is 
not  sufficient  to  properly  drive  the  blood  through  the  brain.  Aconite  in 
one  case,  or  digitalis  in  the  other,  are  good  agents.  If  there  be  much  ex- 
citement, and  the  mind  of  the  individual  be  irritable,  chloral  may  be 
advantageously  administered  either  alone  or  with  the  bromides. 

Ergot  or  its  aqueous  extract  is  sometimes  of  great  benefit  in  these 
cases.     Dr.  Kitchen  has  fully  described  its  virtues,  and  my  own  experi- 


SYMPTOMATIC    CEREBRAL    HYPEREMIA.  89 

ence  is  directly  confirmatory  of  what  he  has  said.  In  doses  of  5j  three 
times  a  day,  the  fluid  extract  may  be  safely  administered.  Squibb's  or 
Bonjean's  watery  extract,  in  five-grain  doses,  may  be  given  alone  or  in 
combination  with  the  bromides.  Should  the  patient  be  very  much  de- 
bilitated, for  this  condition  is  often  connected  with  general  debility, 
we  may  give  strychnise,  phosphorus,  iron,  or  quinine,  though  extreme 
care  should  be  taken  in  deciding  when  they  are  useful  or  contraindicated. 

If  our  patient  should  not  be  able  to  bear  iron,  we  may  substitute  either 
zinc  or  arsenic,  the  oxide  of  the  former  salt  being  most  serviceable.  In 
the  forms  where  this  treatment  is  required,  viz.,  those  where  there  seems 
to  be  a  sluggishness  of  the  circulating  blood,  it  is  well  to  dispense 
with  bromides  or  ergot. 

During  sudden  attacks,  local  blood  letting  is  advisable,  leeches  being 
applied  to  both  ears,  and  cups  over  the  mastoid  processes.  Cold  to  the 
upper  part  of  the  head,  applied  by  means  of  a  bladder  or  ice  bag  filled 
with  cold  water  or  powdered  ice,  isan  important  form  of  treatment.  I 
direct  my  patients  to  apply  cold  to  the  back  of  the  neck  for  fifteen 
minutes,  every  night  and  morning,  and  find  that  it  succeeds  admirably. 

A  drug  spoken  of  before  is  hydrobromic  acid,  which  I  have  found  to 
be  a  valuable  and  powerful  ansemiant. 

^  I  first  advocated  the  use  of  a  solution  of  hydrobromic  acid  in  cerebral 
hyper^emia  some  years  ago. 

Dr.  Fotliergill  in  a  subsequent  article  confirmed  my  views  most  fully, 
and  I  have  since  been  gratified  to  find  how  my  expectations  were  realized 
by  a  more  extended  use  of  the  remedy. 

In  small  doses  it  acts  very  much  as  do  the  bromides,  but  with  much 
more  intensity.  Half  a  drachm  is  fully  equal  to  one  drachm  of  the  bro- 
mide of  potassium.  It  differs,  however,  in  the  want  of  permanence  of  its 
effects,  the  bases  of  the  bromic  salts  seeming  to  favor  retention. 

AVith  regard  to  diet,  and  indulgence  in  alcohol  and  tobacco,  tea  or  cof- 
fee, it  is  impossible  to  lay  down  any  arbitrary  rules.  I  may  begin,  how- 
ever, by  interdicting  all  the  meats  difficult  of  digestion,  and  recommend- 
ing a  non-nitrogenous  diet.  Veal,  corned-beef,  pork,  and  certain  vegeta- 
bles, such  as  cabbage,  cauliflower ;  or  nuts,  spices,  bananas,  and  other 
aromatic  or  fatty  substances,  are  not  to  be  thought  of.  Simplicity  of  diet 
is  to  be  insisted,  upon.  Meats  should  be  broiled,  roasted,  or  baked  ;  and 
vegetables  boiled.  If  the  patient's  comfort  is  dependent  uj)on  tea  or  cof- 
fee, it  would  be  well  to  permit  him  to  indulge  in  them  to  a  reasonable  ex- 
tent. I  do  not  consider  tobacco  the  dangerous  agent  that  it  is  often  said 
to  be,  and  if  the  individual  be  a  smoker,  I  think  his  after-dinner  cigar  need 
not  be  cut  off,  and  a  glass  or  two  of  wine  is  not  in  the  least  harmful. 
Burgundy,  Port,  or  other  full-boiled  wines  should  be  given  up  as  a  matter 
of  course.  The  abuse  of  alcohol  and  tobacco  is  to  be  looked  after  and 
stopped,  if  we  have  any  reason  to  think  that  the  patient  has  these  bad 
habits.  Open-air  exercise  ;  cold  baths,  with  fi'iction ;  or  the  Turkish  bath, 
and  other  agents  that   tend  to   improve  the   cutaneous  circulation,  do  a 

^  Philadelphia  Medical  Times,  October  26,  1876. 


90  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

great  deal  of  good,  and  are  to  be  indulged  in.  We  must  insist  upon  the 
avoidance  of  excitement,  dissipation,  and  late  hours  and  theatre-going  ; 
and  it  may  be  well  to  lay  before  our  patient  what  may  be  the  result  of 
such  imprudence.  Should  we  be  called  in  to  find  that  the  disease  has 
manifested  itself  in  either  of  the  forms  to  which  I  have  alluded  (the 
apopletic,  convulsive,  paralytic,  or  maniacal),  we  must  order  perfect 
quiet,  darken  the  room,  and  use  every  means  in  our  power  to  reduce  the 
cerebral  blood  pressure. 

CEREBRAL  HEMORRHA.GE. 

Synonyms. — Apoplexy.  Hajmorrhagia  cerebria  (Lat.).  Apoplexie 
cerebrale ;  hajmatoeucephalie  ;  coup  de  sang ;  hiemorrhagie  cerebrale 
(Fr.).     Hiruapoplexieen,  Schlagfiiss  (Ger.). 

Definition. — When  through  disease  of  a  cerebral  vessel  its  walls  are 
unable  to  withstand  the  pressure  of  contained  blood,  a  hemorrhage  takes 
place,  and  the  nervous  substance  in  the  neighborhood  is  subjected  to  pres- 
sure, the  severity  of  the  resulting  symptoms  depending  upon  the  impor- 
tance of  the  parts  which  may  be  the  seat  of  the  accident,  and  upon  the 
extent  of  the  hemorrhage. 

Symptoms. — I  have  already  alluded,  when  speaking  of  cerebral 
congestion,  to  light  forms  of  hemiplegia  of  temporary  duration,  which 
were  dependent  upon  slight  hemorrhages  resulting  from  cerebral  conges- 
tion. We  will  now  deal  with  a  form  of  cerebral  hemorrhage  of  a  more 
serious  character,  and  it  may  be  stated  that  the  brain  is  probably  more 
liable  to  hemorrhage  than  any  other  organ,  with  the  exception,  perhaps, 
of  the  spleen.  ^ 

Bastian  has  made  the  classification  which  I  think  it  well,  to  follow. 
He  divides  cerebral  hemorrhage  into  three  forms,  in  regard  to  the  onset 
of  symptoms :  (1)  The  apoplectiform  ;  (2)  the  epileptiform  ;  (3)  the 
simple,  in  which  there  is  neither  lo-s  of  consciousness,  nor  convulsions. 
The  first  may  be  considered  as  a  sudden  and  profound  loss  of  conscious- 
ness, which  may  or  not  disappear ;  but,  if  it  does,  a  certain  amount 
of  hemiplegia  will  remain.  The  epUeptifomi  resembles  the  first,  but,  in 
addition  to  the  coma,  there  are  convulsions.  As  I  have  said,  the  mnjde 
variety  may  not  be  connected  with  any  loss  of  consciousness,  the  patient, 
perhaps,  awaking  in  the  morning  and  finding  himself  deprived  of  power, 
or  noticing  such  a  lo;s  when  some  movement  is  attempted. 

Prodromata. — Cerebral  hemorrhage  occurs  generally  in  individuals  in 
whom  some  well-developed  chronic  trouble  has  paved  the  way.  This  is 
the  rule,  although  in  many  cases  it  may  be  the  result  of  some  recent  dis- 
ease. When  we  come  to  speak  of  pathology  and  morbid  anatomy,  these 
general  diseases,  and  their  influence  in  the  production  of  degeneration  of 
the  cerebral  arteries  will  be  discussed  ;  it  is  only  necess^ary  now  to  de- 
scribe the  forms  of  expression  of  the  preparatory  stages.     It  is  not  always 


^  Bastian  :  Paralysis  from  Brain  Disease,  p.  14. 


CEREBRAL    HEMORRHAGE.  91 

necessary  to  look  for  the  indications  spoken  of  by  Hughlings  Jackson.^ 
"The  careful  cliuical  observer  considers  minor  degenerative  changes, 
baldness,  grayness  of  hair,  the  state  of  skin,  and  worn  teeth.  He  in- 
quires for  the  history  of  gout  and  intemperance," 

The  appearance  of  those  individuals  in  whom  an  apoplectic  effusion 
may  be  looked  for,  may  be  of  two  kinds.  1.  The  thick-necked,  red-faced, 
and  full-blooded.  2.  The  fair,  long-necked,  or  aged  persons,  in  whom 
the  radial  arteries  are  hard,  and  feel  very  much  like  strings  of  beads  or 
pipe-stems  beneath  the  skin.  The  existence  of  renal  trouble  also  con- 
tributes to  the  development  of  an  arterial  state  which  favors  rupture, 
and  we  should  search  for  other  indications  of  this  trouble.  Many  of  the 
symptoms  of  cerebral  hypersemia  may  be  precursors  of  those  that  follow 
cerebral  hemorrhage.  For  several  days  the  patient  may  have  headache, 
formication  at  the  extremities  as  if  pins  and  needles  were  being  thrust 
into  the  skin,  perhaps  a  slight  ansesthesia  of  the  arm  or  leg  of  one  side; 
his  speech  may  be  thick  and  clumsy,  or  he  may  drop  a  word  here  and 
there,  and  his  eyes  may  be  red  and  full  of  tears ;  dizziness,  muscse 
volitantes  dependent  upon  retinal  isehiemia,  and  nose-bleed  may  all  be 
indications  of  increased  blood  pressure.  These  last  two  forerunners  of 
cerebral  hemorrhage  may  recur  at  intervals  for  some  time  before  the 
actual  rupture  of  the  vessel.  The  retinal  trouble  may  be  of  long  dura- 
tion, and  is  of  decided  importance  as  an  evidence  of  the  degenerate  con- 
dition of  the  cerebral  vessels,  and  should  invariably  be  regarded  with 
suspicion.  An  atrophy  of  the  optic  papillse  with  spots  of  blanching  at 
the  fundus,  such  as  we  find  to  be  the  result  of  Bright's  disease,  is  also 
suggestive  at  times  of  a  tendency  to  cerebral  hemorrhage.  To  this  list 
of  prodromata  may  be  added  vomiting  and  stupor ;  but  these  are  con- 
nected with  so  many  varieties  of  brain  disease  that  they  may  only  be  con- 
sidered as  important  when  occurring  in  conjunction  with  the  trouble  to 
which  I  have  just  alluded.  A  very  serious  premonitory  symptom  is  paraly- 
sis of  one  limb  or  certain  isolated  muscles,  which  indicates  organic  dis- 
ease. After  a  variable  time,  during  which  some  or  all  of  these  antece- 
dent symptoms  may  be  observed,  the  vascular  accident  may  occur.  Its 
onset  may  take  place  in  two  ways  :  (a)  In  connection  with  profound 
loss  of  consciousness  and  suddenly.  (6)  Gradually,  without  loss  of  con- 
sciousness. We  may  call  the  first  the  apoplectic  attack.  Its  common 
history  is  the  following,  and  we  may  take  as  an  illustrative  case  a  male 
aged  50.  The  patient,  who  is  of  full  habit,  short,  red-faced,  and  cor- 
pulent, had  probably  led  a  rather  dissipated  life.  V^'hile  reading  his 
paper,  after  an  unusually  hearty  dinner,  he  suddenly  falls  to  the  floor  in 
an  unconscious  condition ;  his  breathing  is  stertorous,  the  cheeks  and 
lips  being  pufied  out  by  each  expiration  ;  his  face  is  dark,  or  perhaps 
very  pale,  the  pupils  dilated  and  insensible  to  light,  and  his  eyeballs  are 
fixed,  turned  upward,  and  drawn  to  one  side.  If  the  nostril  be  tickled 
no  reflex  movements  follow,  and  the  same  is  the  case  if  the  soles  of  the 

1  Cerebral  lieiuorrhage,  '•Reynolds'  System  of  Medicine." 


92  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

feet  be  titillated.  He  is  limp,  and  lies  upon  the  floor  in  an  inanimate 
heap ;  the  pulse  will  be  found  to  be  hard  and  full,  but  not  very  rapid, 
and  if  his  temperature  be  taken  it  will  be  probably  not  exceed  97°,  or 
perhaps  is  half  a  degree  lower.  He  is  taken  up  and  placed  in  bed,  and 
after  a  while  may  make  some  slight  voluntary  movement  with  the  limbs 
of  one  side  of  the  body.  It  will  be  seen  that  the  others  are  without 
power,  for  if  the  leg  or  arm  of  the  paralyzed  side  be  lifted  and  released 
it  will  fall  to  the  bed  as  a  dead  weight.  After  an  hour  or  two,  tickling 
of  the  sole  of  the  unaffected  foot  will  be  followed  by  a  drawing  up  of  the 
sound  leg.  The  eyes  are  still  rolled  up  and  turned  away  from  the  para- 
lyzed side  of  the  body,  and  the  edges  of  the  irides  are  covered  by  the 
inner  canthus  of  one  palpebral  commissure,  and  by  the  outer  canthus  of 
the  other.  The  eyeballs  may  be  sometimes  slightly  agitated  by  a  feeble 
movement  of  a  nystagmic  character.  It  will  be  found,  on  removing  the 
patient's  clothing,  that  he  has  unconsciously  voided  his  urine  and  feces. 
This  condition  may  last  for  a  few  hours,  the  coma  remaining  profound, 
and  the  temperature  rising  to  103  to  105  degrees,  and  the  pulse  advanc- 
ing, when  death  takes  place  ;  or  it  may  be  followed  in  an  hour  or  two 
by  slight  signs  of  returning  intelligence,  an  increase  of  temperature,  say 
to  100°,  with  slight  abatement  of  the  regular  respiration,  disappearance 
of  stertor,  and  the  unnatural  deviation  of  the  eyes,  when  his  temperature 
may  return  to  the  normal  standard,  and  the  patient  so  far  recover  con- 
sciousness as  to  be  able  to  recognize  those  about  him,  and  express  him- 
self by  simple  words,  as  "yes"  or  "no."  The  urine  has  to  be  drawn 
for  a  day  or  two,  and  the  bed-pan  used,  as  the  bladder  and  rectum  are 
implicated. 

This  form  of  cerebral  hemorrhage  may  be  connected  with  an  epilepti- 
form attack  in  the  beginning,  and  the  convulsion  may  be  either  confined 
to  one  side  or  be  general.  It  would  be  well,  before  going  further,  to 
dwell  upon  certain  elements  of  the  apoplectic  attack  and  analyze  the 
symptoms. 

THE    PSYCHICAL   DISTURBANCES. 

Sudden  compression  of  the  cerebral  mass  is  always  attended  by  uncon- 
sciousness, but  it  is  a  seriolis  fact  that  slowly  developed  growths,  such  as 
large  tumors  or  abscesses,  seem  to  accommodate  themselves  to  the  sur- 
rounding tissues,  so  that  sometimes  no  loss  of  consciousness  occurs  what- 
ever. I  have  seen  a  large  abscess  occupying  an  extensive  tract  of  one 
hemisphere  without  producing  the  least  loss  of  consciousness.  The  large 
effusions  which  produce  unconsciousness  are,  in  the  opinion  of  Mr.  Hutch- 
inson,^ productive  of  the  psychical  condition,  by  inducing  anemia  of  other 
parts  thi'ough  sudden  pressure.  Small  clots  are  undoubtedly  productive 
of  suspended  consciousness,  by  cutting  off  either  a  large  vessel,  or  by  in- 
jury to  some  important  sensory  ganglion. 

Consciousness  is  either  restored  through  the  re-establishment  of  the 

^  London  Hospital  Reports,  vol.  iv.,  1867. 


CEREBRAL    HEMORRHAGE.  93 

blood  supply  or  the  subsidence  of  shock,  except  where  the  hemorrhage 
has  taken  place  in  the  medulla.  The  variation  in  the  loss  of  conscious- 
ness is  of  great  importance  to  the  physician,  especially  in  regard  to  prog- 
nosis. In  severe  cases  there  may  be  slight  improvement  in  this  respect. 
The  patient's  intelligence  returns  to  such  a  degree  as  to  inspire  his  friends 
with  some  degree  of  hope ;  but  there  is  often  a  sudden  relapse  to  the  ori- 
ginal state  of  coma,  dependent  upon  fresh  hemorrhage. 

RESPIRATORY     DISTURBANCES. 

Stertor  is  an  important  symptom,  and  should  always  be  looked  upon 
with  alarm.  It  is  indicative  generally  of  some  lesion  of  the  base,  and 
nearly  always  lasts  until  death,  if  there  be  a  very  large  effusion,  but  dis- 
appears after  a  few  hours  if  recovery  is  to  take  place.  Kespiration  un- 
dergoes very  decided  modification.  Hughlings  Jackson,^  in  speaking  of 
disturbed  respiration,  says :  "  Again,  not  only  is  the  rate  of  respiration  to 
be  considered,  but  the  character  of  the  respiratory  movements  are  to  be 
noted.  As  they  quicken  in  rate,  so  do  .they  become  more  extensive  in 
range  though  such  respiration  is  still  short.  Thus  in  the  first  stage  there 
may  be  only  quiet  action  of  the  diaphragm,  but  at  length  the  sides  of  the 
chest  evert  strongly  in  inspiration,  the  abdominal  movement  being  less 
obvious,  and  at  length  the  upper  thorax  takes  part  in  the  process.  In 
severe  cases  the  epigastrium  sinks  in  during  inspiration.  This  is  proba- 
bly partly  owing  to  elevation  of  the  attachments  of  the  diaphragm  from 
increased  action  of  the  sides  of  the  thorax,  and  partly  to  pushing  down 
of  the  diaphragm  by  increasing  bulk  of  the  lungs  from  congestion  or 
oedema  " 

CONDITION   OF  THE    EYES. 

Prevost,^  Vulpian,  Lockhart  Clark,  and  others  were  among  the  first  to 
call  attention  to  a  peculiar  diagnostic  point  which,  though  not  always 
jDresent,  is  of  great  value  when  it  occurs.  This  has  been  known  as  "  con- 
jugate deviation.'"  During  the  apoplectic  condition  the  eyes  of  the  in- 
dividual will  be  fixed,  so  that  they  look  upwards  and  outwards,  towards 
the  side  of  the  lesion,  and  away  from  the  j^aralyzed  side  of  the  body ;  the 
only  excej)tion  being  when  the  lesion  is  in  or, behind  the  pons.  It  is 
more  often  seen  when  the  attacks  are  sudden,  and  it  is  a  phenomenon  of 
short  duration,  lasting  at  the  most  but  a  few  days.  During  sleep  the 
condition  subsides,  and  the  eyeballs  are  restored  to  their  normal  state, 
but  immediately  on  awaking  they  return  to  this  position,  and  in  spite  of 
the  patient's  effort  the  axis  of  vision  cannot  be  changed.  When  the  ef- 
fusion is  a  large  one,  or  when  the  onset  is  epileptiform,  the  pupils  are  at 
first  very  wildly  dilated ;  but  when  there  exists  a  lesion  in  the  pons  the 
pupil  which  corresponds  to  the  sides  of  the  lesion  is  greatly  contracted. 
Unequal  dilatation,  however,  is  not  of  very  great  diagnostic  value.  If  a 
lesion  in  the  pons  be  extensive,  both  are  contracted. 

1  Op.  cit.,  p.  548.  2  Gazette  Hebdom.,  Oct.  13, 1865. 


94  DISEASES     OF     THE     CEREBRUM     AND     CEREBELLUM. 

TEMPERATURE   AND    PULSE. 

Thanks  to  Bourncville,'  we  are  enabled  to  study  systematically  the 
variations  of  temperature.  He  divides  the  cases  into  four  groups  :  1. 
Copious  cerebral  hemorrhage,  rapidly  fatal,  and  attended  by  lowered  tem- 
perature. 2.  Cerebral  hemorrhage,  terminating  fatally  in  from  one  to  two 
days,  in  which  the  temperature  is  primarily  lowered  and  afterward  height- 
ened. 3.  Fatal  cases  in  which  death  takes  place-in  from  two  to  six  days. 
In  these,  as  in  other  forms,  there  is  at  first  depressed  temperature,  next  a 
return  to  the  normal  standard,  with  slight  variations,  and  finally  a  decided 
rise.  4.  Favorable  cases,  in  which  there  are  the  primary  lowering,  a  sec- 
ondary rise,  and  final  return  to  the  standard  of  health. 

These  variations  in  temperatui'e  range  between  96  and  108  degrees 
(rectal  temperature).  The  pulse  variation  bears  but  slight  rela- 
tion to  the  fluctuation  of  the  body  heat.  In  the  four  classes  spoken 
of,  we  may  consider  in  the  first,  that  the  pulse  is  full  and  slow,  ranging 
from  55  to  6o.  With  the  rise  of  temperature  which  characterizes  the 
others,  it  becomes  greatly  accelerated,  beating  oftentimes  120  to  130  per 
minute,  losing  its  full  character,  and  becoming  small  and  irritable,  and  if 
death  occurs,  grows  gradually  weaker.  If  recovery  follows  the  attack, 
there  is  a  gradual  return  to  its  normal  rate.  Of  course,  this  must  be  a 
very  unsatisfactory  con5ideration  of  the  state  of  the  pulse,  for  the  apoplec- 
tic condition  is  not  always  the  same,  collapse  and  reaction  varying  greatly 
in  regard  to  their  occurrence  and  duration  ;  so  the  pulse,  as  well  as  respira- 
tion and  temperature,  undergoes  many  irregular  modifications. 

ATTACKS   WITHOUT   LOSS   OF    CONSCIOUSNESS. 

The  other  form,  in  which  the  individual  preserves  his  consciousness,  is 
not  so  serious  a  condition  as  that  just  described.  The  person  may  present 
some  of  the  premonitory  symptoms  already  mentioned,  or,  on  the  other 
hand,  may  receive  no  warning,  but  while  engaged  in  any  ordinary  occu- 
pation may  suddenly  find  one-half  of  his  body  to  be  paralyzed,  and  be  un- 
able to  communicate  with  those  about  him,  there  being  slight  aphasia. 
With  the  paralysis  there  may  be  anaesthesia.  This  state  of  affairs  may 
begin  during  the  night,  and  on  awakening  in  the  morning  he  may  find  it 
impossible  to  leave  his  bed.  The  paralysis  is  sometimes  gradual,  the  loss 
of  power  affecting  one  member,  and  afterwards  the  other,  an  unexpected 
feebleness  being  suddenly  noticed  as  he  is  about  to  perform  some  act.  One 
of  my  patients,  an  acrobat  of  dissolute  habits,  while  preparing  for  the 
performance,  found,  when  he  attempted  to  put  on  his  tights,  that  his  right 
leg  was  quite  powerless;  he  made  an  effort  to  stand,  but  became  dizzy, 
and  grasped  for  support  a  pole  that  was  near.  After  repeated  efforts  to 
dress  he  abandoned  the  attempt,  summoned  assistance,  and  was  taken 
home;  the  same  night  the  right  upper  extremity  was  affected.     He  had 

^  Eludes  cliniques  et  thermometriques  sur  les  Maladies  du  Svsteme  nerveiix. 
Paris,  1872. 


CEREBRAL    HEMORRHAGE.  95 

never  had  any  previous  warning.  Attacks  of  this  kind  may  be  the  fore- 
runners of  others  of  a  more  serious  nature.  In  illustration,  may  be  men- 
tioned the  case  of  S.  C,  a  married  woman,  aged  41.  She  was  drawing 
Avater  at  a  sink,  when  she  became  suddenly  giddy,  and  had  to  take  hold  of 
the  banisters  to  steady  herself.  She  stood  thus  until  some  friends  put 
her  into  a  chair  and  carried  her  to  her  room.  She  sat  there  that  day,  and 
was  helped  to  bed,  but  did  not  discover  her  paralysis  until  next  morning. 
Was  not  unconscious  at  any  time  of  the  attack.  Her  paralysis,  when  she 
discovered  it,  was  somewhat  worse  than  it  is  at  present,  and  she  could  not 
speak  as  well  as  she  now  does.  A  few  days  after  the  attack  she  went  to 
a  hospital,  where  she  remained  one  month.  She  entered  the  Epileptic 
Hospital  July  6,  1875,  and  was  put  upon  strychnine  and  belladonna,  there 
existing  an  inability  to  retain  her  urine,  I  take  the  notes  of  her  subse- 
quent history  from  the  case-book  of  the  hospital. 

"  Sejot  22.  At  7.30  last  night  it  was  noticed  that  she  could  not  speak  as 
well  as  formerlj'-.  It  was  quite  difficult  for  her  to  speak  so  as  to  be  under- 
stood. She  laughed  a  little  immoderately  at  her  inability  to  clearly  enun- 
ciate the  words. 

"  An  hour  afterwards,  in  attempting  to  leave  her  bed,  she  fell,  and  since 
then  has  been  scarcely  able  to  speak,  and  can  only  say  a  few  words.  No 
other  symptoms  were  noticed.  Her  strength  of  muscle  and  sensibility 
seems  unaffected.  She  cries  now  continually,  and  seems  to  be  depressed 
because  she  cannot  speak. 

"  Oct.  13.  Patient  can  tell  her  name,  and  can  name  every  article  shown 
her.     A  little  thickness  in  articulation. 

"  Pupils  react  well.  Lenses  of  eyes  are  a  little  opaque  —the  left  a  little 
more  than  the  right.  Face  palsy  almost  passed  away.  Lower  facial 
muscles  act  well.  Sensibility  in  face  fair.  Tongue  points  slightly  to  the 
right. 

"  Voluntary  motion  abolished  in  right  upper  extremity,  the  least  motion 
in  shoulder  excepted.  Articulations  are  all  flexed  in  the  right  upper 
extremity,  and  the  contracture  is  greatest  in  the  hand,  the  fingers  almost 
touching  the  palm.     Elbow  and  shoulder  are  less  rigid. 

"  Extension  is  not  painful,  and  there  are  no  spontaneous  pains  in  arm. 
Sensibility  to  contact  in  hand  good.  On  finger  tips  feels  the  points  of 
sesthesiometer  at  three  millimetres.  There  is  no  numbness  in  hands.  Pa- 
tient considers  the  paralyzed  hand  the  warmer  of  the  two.  Between  index 
finger  and  middle  finger  of  right  hand  in  three  minutes'  time  the  tempera- 
ture is  98°.  Same  place  on  left  hand  in  three  minutes'  time  temperature 
is  98}°.  Right  lower  extremity,  no  motion  in  toes  and  ankles,  consider- 
able motion  in  knee  and  hips,  no  numbness,  no  contraction. 

THE   RESIDUAL   PARALYSIS. 

A  paralysis,  remaining  after  the  "  apoplectic  stroke,*'  is  generally  uni- 
lateral, though  in  rare  cases,  where  the  pons  is  affected  at  the  central 
portion,  the  paralysis  may  exist  on  both  sides  of  the  body;  this  one-sided 
paralysis  is  known  as  Hemiplegia,  and  may  be  complete  or  incomplete  as 


96  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM, 

regards  sensation  and  motion.  AVhen  we  examine  our  patient  after  the 
immediate  grave  symptoms  have  to  some  degree  subsided,  we  will  find  the 
limbs  of  one  side  limp,  powerless,  and  genei'ally  without  sensation ;  the 
face  jjaralyzed  on  the  same  side,  and  its  other  half  drawn  up  by  the  healthy 
muscles,  as  their  antagonists  are  unable  to  perform  their  functions.  If  the 
patient  be  sensible  enough  to  put  out  his  tongue,  it  will  point  to  the  para- 
lyzed side,  while  the  eyes,  if  conjugate  deviation  exists,  will  turn  in  an 
opposite  direction  in  a  manner  already  described. 

Jastrowitz^  has  called  attention  to  a  peculiar  symptom,  the  tendency  of 
the  patient  to  slip  out  of  bed  on  the  unaffected  side.  This  is  caused  by 
the  inability  of  the  paralyzed  limb  to  support  the  weight  of  the  sound 
part  of  the  body.  He  also  alludes  to  the  fact,  when  pressure  is  made  on 
the  sapheua  nerve,  at  the  point  where  the  vastus  externus  makes  a  groove 
with  the  vastus  internus,  that  the  cremaster  muscle  on  the  paralyzed  side 
will  not  draw  up  the  testicle,  which  is  not  the  case  on  the  other  side  of 
the  body.  In  other  forms  of  paralysis,  to  be  hereafter  described,  there  is 
not  the  same  uniformity  of  symptoms  there  being  perhaps  paralysis  of 
special  cranial  nerves,  or  those  of  the  muscles  of  the  face  on  the  side  op- 
posite to  the  body  paralysis.  This  variety  has  been  called  cross  paralysis. 
Both  sides  of  the  face  or  both  sides  of  the  body  may  be  involved,  in 
which  event  there  is  a  speedy  fatal  termination.  Occasionally  the  mus- 
cles of  the  pharynx  may  be  paralyzed,  and  sometimes  the  larynx,  A 
case  of  this  latter  kind  is  reported  by  Luys.^  He  mentions  the  ease  of 
"  a  woman  who  had  a  sudden  attack  of  apoplexy  with  hemiplegia  of  the 
left  side,  but  with  no  disturbance  of  sensibility  or  of  the  organs  of  special 
sense.  The  congestive  phenomena  of  the  onset  being  calmed  little  by 
little,  the  patient  regained  consciousness,  and  stated  that  four  years 
previously  she  had  been  struck  for  the  first  time  with  left  hemiplegia,  and 
since  then  had  been  aphonic.  Her  intelligence  was  good,  and  she  spoke 
distinctly,  but  in  a  low  voice.  She  had  no  paralysis  of  the  tongue,  the 
soft  palate,  or  the  lips.  A  few  days  later,  she  was  seized  with  new  con- 
gestive symptoms,  and  died  insensible." 

This  laryngeal  paralysis  is  undoubtedly  a  much  more  common  affection 
than  it  is  generally  supi:)osed  to  be,  and  the  probability  is  that  many  of 
the  cases  reported  as  aphasic  are  in  all  probability  ai)honic.  Our 
patient,  after  his  return  to  consciousness,  will  then  be  found  to  be  hemi- 
plegic,  and,  if  he  is  amused  and  attempts  to  laugh,  we  will  plainly  notice 
facial  distortion,  which  follows  any  such  efforts.  The  surface  temperature 
of  the  paralyzed  parts  is  usually  higher  than  on  the  other  side,  and  the 
limbs  may  seem  to  be  of  greater  contour,  and  true  arthropathies  may  be 
presented.  This  appearance  has  been  noticed  by  Hitzig,'  who,  in  refer- 
ring to  Charcot's  cases,  presents  seven  of  his  own,  in  all  of  which  there 
was  incomplete  dislocation  of  the  head  of  the  humerus,  with  irregular 

1  Berliner  Klin.  Woch.,  Aug.  2,  1875. 
^  La  France  Medicale,  Sept.  28,  1875, 
^  Virchow's  Archiv,,  xlviii.,  p.  345. 


CEREBRAL    HEMOEEHAGE.  97 

pains  of  the  arm,  increased  by  pressure.  The  paralyzed  arm  was  swollen, 
warmer  and  more  moist  than  its  fellow,  and  the  pains  alluded  to  began 
about  six  weeks  after  the  apoplectic  attack.  Hitzig  is  of  the  opinion  that 
this  condition  of  affairs  is  not  directly  dependent  upon  the  central  lesion. 
Voluntary  power  is  lost  in  proportion  to  the  extent  and  situation  of  the 
lesion.  Should  it  be  in  the  cortex  or  corpus  striatum,  a  very  small  lesion 
may  produce  very  decided  impairment  of  motility,  while  such  is  not  the  case 
in  the  white  matter  of  the  hemispheres.  It  will  generally  be  found  neces- 
sary to  draw  the  patient's  urine  for  a  few  days,  for  the  bladder  loses  its 
expulsive  force,  and,  if  this  procedure  be  not  resorted  to,  there  may  be 
retention.  Electric  contractility  seems  to  be  exaggerated  at  first  in  the 
paralyzed  limbs,  and  a  very  weak  electric  current  may  provoke  the  most 
energetic  contractions.  In  certain  cases  there  may  be  an  increase  of  re- 
flex excitability  and  tactile  sensibility.  Sensations  may  be  even  some- 
times reversed,  warmth  being  felt  as  cold,  or  vice  versa,  or,  as  in  the  case 
quoted  by  Bastian,^  a  warm  object  may  be  appreciated  as  a  weight.  "  A 
hot  body  on  the  face  was  recognized  as  pressure  only ;  on  the  arm  it  was 
felt  as  such,  though  the  sensation  was  not  distinctly  localized,  whilst  on 
the  left  leg  the  same  hot  body  was  recognized  correctly  as  regards  situa- 
tion, though  it  gave  rise  only  to  a  feeling  of  tingling."  I  have  often 
witnessed  hypersesthesia  of  the  paralyzed  limbs,  which  were  very 
tender  to  the  touch.  Ansesthesia  generally  exists,  however,  and  electric 
sensibility  is  greatly  diminished.  At  the  end  of  a  few  days  it  is  not  un- 
common to  find  marked  rigidity  of  the  paralyzed  limbs,  increased  reflex 
excitability,  and  other  evidences  of  slight  cerebritis  at  the  seat  of  the 
clot.  The  tendon  reflex  is  markedly  increased  in  the  paralyzed  limb,  and 
the  slightest  tap  will  evolve  an  energetic  contraction.  Gradually  there 
is  a  return  to  the  normal  condition,  and  articulation,  which  was  imper- 
fect in  the  beginning,  may  become  more  distinct,  or,  should  there  be 
aphasia,  the  patient  will  begin  to  command  a  greater  number  of  expres- 
sions. A  week  or  so  passes,  and  he  is  able  to  protrude  his  tongue  in  a 
much  straighter  line  than  before,  while  the  paralyzed  muscles  of  the  face 
slowly  recover  their  lost  power  ;  but  when  the  levator  palpebral  is  para- 
lyzed and  ptosis  results,  restoration  is  much  more  slow.  In  regard  to  this 
paralysis,  Bastian  has  reminded  us  that  very  often  deformities  exist,  such 
as  the  absence  of  teeth  on  one  side,  which  may  produce  an  appearance  of 
facial  paralysis,  when  in  reality  none  exists.  This  is  seemingly  a  trivial 
matter,  but  its  neglect  is  likely  to  lead  to  grave  en-ors  in  diagnosis  and 
prognosis.  As  months  go  by,  gradual  amelioration  of  the  patient's  con- 
dition takes  place,  the  limbs  regain  their  power,  the  leg  first,  and  finally 
the  arm,  and  the  patient  may  be  at  first  able  to  move  his  toes,  then  to 
raise  his  leg,  and,  when  he  leaves  his  bed,  gradually  begins  to  acquire 
power  of  locomotion.  The  walk  of  the  hemiplegic  is  not  to  be  mis- 
taken ;  his  gait  is  shufiling,  the  toe  of  the  boot  is  dragged  over  the  ground, 
and  the  leg  thrown  outwards  and  forwards,  the  knee  being  stiff",  and  the 

1  Op.  cit.,  p.  128. 


98  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

arm  swung  helplessly  by  the  side.  As  the  gait  improves,  and  the  pa- 
tient gains  more  control  over  his  limbs,  he  is  able  to  perform  movements 
which  require  the  action  of  the  muscles  of  the  hip-joint,  knee-joint, 
and  finally  the  ankle  and  toes.  Should  he  only  partially  recover, 
numerous  secondary  conditions  may  follow,  as  results  of  non-improvement 
of  the  cerebral  condition.  These  are  chiefly  of  a  motorial  character,  and 
consist  of  spasms,  permanent  contractures,  bed  sores,  atrophy,  and  in- 
flammations of  nerve-trunks.     Such  sequela  may  be  called — 

THE    POST-PARALYTIC   STATES. 

I  may  enumerate  these  as — 1.  Permanent  contractures ;  2.  Trophic  al- 
terations; 3.  Tremor(post-paralyticchoreaof  Mitchell  and  Charcot);  and, 
4.  Slow  clonic  spasms  (so-called  athetosis). 

Of  32  cases  of  old  hemiplegia  seen  by  Bouchard  ^  at  La  Salp^tri^re,  in 
31  there  were  paralytic  contractures.  The  other  case  presented  what  he 
called  I'hemiplegie  fiasque.  This  form  is  of  slow  appearance,  and  affected 
in  the  beginning  the  muscles  of  the  forearm.  The  fingers  were  flexed, 
and  the  forearm  was  pronated  and  flexed  on  the  arm,  and  at  the  same 
time  the  humerus  was  drawn  to  the  trunk. 

According  to  Strauss,^  this  form  presents  several  variations,  and  some- 
times the  hand  is  brought  in  contact  with  the  trunk,  either  on  its  palmar, 
dorsal,  or  radial  aspects.  Of  a  large  number  of  cases  that  have  come 
under  my  observation,  I  have  found  that  deformities  of  the  upper  extre- 
mities are  much  more  common  than  of  the  lower ;  the  fingers  are  com- 
monly flexed  and  rarely  extended,  while  the  muscles  of  the  trunk  seem 
to  be  exempt  from  this  change ;  and,  indeed,  I  cannot  call  to  mind  a 
single  instance  of  this  kind.  Contractures  of  the  muscles  of  the  lower 
extremities  are  apt  to  produce  deformities  which  resemble  talipes,  equinus 
varus  or  valgus,  and  the  toes  are  flexed  upon  the  sole.  Contractures  of 
the  facial  muscles  are  quite  rare,  and  of  late  appearance.  The  deformi- 
ties are  always  quite  striking,  because  of  the  antagonistic  action  of  unaf- 
fected muscles,  and  usually  no  amount  of  force  can  overcome  them. 
Trophic  changes  are  by  no  means  rare,  either  in  connection  with  contrac- 
tured  muscles  or  alone.  I  have  now  several  patients  under  observation 
who  are  hemiplegic.  In  one  of  these  the  skin  of  the  paralyzed  hand  is 
white  and  puffed  up ;  the  heads  of  the  phalanges  and  metacarpal  bones 
are  reduced  in  size,  so  that  there  is  no  enlargement  at  their  points  of  ar- 
ticulation, and  a  consequent  depression  exists.  In  other  cases  there  is 
considerable  muscular  atrophy  to  be  witnessed  in  the  palm  of  the  hand ; 
and  in  others  the  bones  of  the  arm  are  greatly  diminished  in  size,  and  the 
interossei  quite  wasted  away. 

Charcot^  has  written  extensively  about  a  form  of  neuritis  following 
cerebral  lesions,  which  is  supposed  to  be  of  a  central  nature.  That 
ascending  (from  the  periphery  to  the  centre)  neuritis  sometimes  takes 

^  Des  Contractures,  Pari.s,  1875,  p.  16.  ^  Op.  cit. 

3  Legons  sur  les  Maladies,  etc.     Fasc.  1,  and  previous  articles. 


\ 


CEREBRAL    HEMORRHAGE.  99 

place  after  cerebral  hemorrhage  there  can  be  uo  manner  of  doubt;  and  in 
one  case,  at  present  under  observation,  the  neuritis  began  at  several  dif- 
ferent peripheral  points  of  the  nerve,  and  there  were  consequent  atrophic 
muscular  changes.^  The  form  of  neuritis,  however,  most  deserving  atten- 
tion is  that  known  as  secondary  degeneration,  described  quite  fully  since 
the  first  edition  of  this  book,  especially  by  Flechsig,  Charcot,  and  Bris- 
saud.  It  is  pathologically  the  invasion  of  the  motor  tracts,  which  extend 
downwards  involving  the  pyramidal  parts  of  the  lateral  columns  of  the 
cord,  and,  as  a  result,  we  find  beside  loss  of  motor  power,  the  appearance 
of  contractures  and  an  exaggeration  of  the  tendinous  reflex.  The  disor- 
ders of  motility  are  numerous,  and  depend  more  or  less  upon  the  lost  or 
impaired  inhibitory  power  of  the  individual,  and  the  paralyzed  muscles 
which  are  their  seat. 

Dr.  Gowers^  presents  the  following  excellent  table,  which  embraces  all 
the  disturbances  of  motility  which  may  occur  after  the  hemiplegic 
attack : 


POST-HEMIPLEGIC   DISORDERS    OF   MOVEMENT. 

r  Tremor 


Fine. 


Coarse. 
f  Regular  (continuous,  or  on  movement)  J 

^   Certain,    regular,    move- 
«  j      ments,  due  to  interos- 

Quick,  clonic  spasm,  of     j  L     sei,  pronators,  etc. 

intermitting  type.  i 

I  r  Choreoid     C  Continuous 

\  \  spasm,  or 

L,  Regular  (continuous,  or  on  movement)  -l  <  inco-ordi- 

l  1  nation   of 

V  Jerking       V.  movement. 

{Continuous="  Athetosis  " 
On  movement  =slow,  cramp-like,  inco-    "j 
ordination  [  "  Spastic   contracture  "  of 

[       hemiplegic  children. 
Tonic  spasm,  varying         fOf  interossei,  conspicuous  J 


Fixed  rigidity,  unvarying  ^Of  flexor-longua  digitorum,  conspicuous  Jate  rigidity. 

The  individual  retains  but  little  of  his  control  over  the  affected  muscles, 
though  voluntary  power  exists  usually  to  a  variable  extent  The  in- 
fluence of  the  will  though  often  increases  spasmodic  movements.  Spasms 
and  tremor  afiect  first  the  smaller  muscles,  while  tonic  spasms  affect  the 

^ These  trophic  muscular  and  cutaneous  changes  are  of  a  most  interesting  nature 
Duncan*  found  in  one  case  that  an  eruption  had  appeared  on  the  thigh  of  the 
paralyzed  side  which  disappeared  with  the  return  of  power;  and  Charcot f  and 
Payne  J  another.  In  a  case  mentioned  by  the  former,  a  vesicular  eruption  appeared, 
which  followed  the  distribution  of  the  superficial  ramifications  of  the  peroneal  nerve, 
and  was  coincident  with  the  hemiplegia.  In  this  case  the  hemiplegia  followed  em- 
bolism, and  a  branch  of  a  spinal  artery  (rami  medullse  spinales,  of  Rudinger)  was 
found  obstructed  by  a  plug.  Pressure  had  been  made  on  the  spinal  ganglion  from 
which  one  of  the  branches  of  the  sciatic  originates. 

^Med.  Chir.  Trans.,  vol.  lix. 


*  Journ.  of  Cutaneous  Med.,  Oct.  1868,  p.  69 ;  quoted  by  Charcot. 
t  Op   cit.,  p.  72.  t  Br.  Med.  Journ.,  Aug.  1871. 


100        DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

larger  muscles  of  the  limbs.  One  form  of  tremor  of  a  post-liemiplegic 
character  has  been  called  by  Mitchell  "  post-paralytic  chorea  ;  "  the  tre- 
mor is  suggestive  of  sclerosis,  and  may  begin  within  a  period  ranging  from 
one  to  several  months,  affecting  generally  the  upper  extremities,  and  it  is 
aggravated  by  any  exercise  of  volition.  It  may  affect  both  extremities, 
but  very  rarely  the  face,  and  the  movements  are  quite  coarse,  and  may 
be  associated  with  a  certain  amount  of  hemi-anresthesia.  A  variety  of 
movement  of  a  clearly  post-hemiplegic  character  has  been  elevated  to  a 
distinct  position,  and  given  the  name  "athetosis"  by  Hammond.  As 
this  condition  is  ordinarily  a  secondary  affection  to  other  neuroses  as  well 
as  hemiplegia,  the  undue  prominence  which  it  has  received  is  entirely 
undeserved.  Gowers  says :  "  Neither  clinical  history  nor  supposed 
pathology  of  athetosis  affords  ground  for  separating  it  from  other  forms 
of  disordered  movement  commonly  seen  after  hemiplegia,  but  any  one  of 
which  might  occur  in  the  primary  affection."  Charcot^  refuses  to  ac- 
knowledge its  distinct  character.  He  presents  several  cases,  all  of  which 
followed  some  form  of  hemiplegia ;  and  the  literature  of  neurology  is  re- 
plete with  examples  of  so-called  athetosis  which  are  generally  connected 
with  hemiplegia,  chorea,  or  even  hysteria. 

^Brissaud  has  studied  the  particular  features  of  the  rigidity  of  late  hemi- 
plegia, or,  as  he  calls  them,  the  "permanent  contractures  of  hemiplegia," 
which  are  found  to  involve  the  flexor  muscles.  There  are  often  what  are 
called  associated  movements ;  for  instance,  when  one  of  his  patients  was  told 
to  firmly  close  her  left  hand  forcibly  it  was  found  that  the  movement  of 
flexion  of  this  hand  was  always  accompanied  by  slow  movement  of  flexion 
o{  the  right  moreover  that  when  she  opened  and  shut  her  left  hand  a 
number  of  times,  the  right  became  closed  in  the  position  of  true  con- 
tracture. This  genesis  of  movements  in  the  sound  side  is  a  feature  of  old 
contracture. 

The  easy  production  of  an  increased  tendinous  reflex  is  always  possible, 
and  whether  the  tendons  are  lightly  tapped  or  the  member  flexed  or  jarred 
there  is  a  tetanoid  state,  or  a  series  of  spasms  produced  and  the  increased 
knee  reflex  commences,  according  to  Brissaud,  as  soon  as  the  appearance 
of  secondary  contracture  begins.  The  myograph  has  been  used  to  test  the 
tendon  reflex  in  hemiplegia.  By  the  attachment  of  an  ingenious  instru- 
ment, constructed  by  Dr.  F.  Franck,  it  was  possible  to  make  some  very  val- 
uable records,  showing  the  duration  of  the  reflex,  the  amplitude  of  the  con- 
traction and  its  character.  ^Tochirjew  and  *Burckhardt  established  the 
duration  of  the  normal  reflex  at  from  32  to  34-thousandths  of  a  second,  while 
Gowers  believes  the  time  to  be  longer.  Brissaud  has  fixed  the  time  at 
50-thousandths  of  a  second,  as  that  in  which  the  reflex  occurs  in  the  nor- 
mal state. 

'  Op.  cit,  4th  part,  p.  493. 

^  Recberches,  etc.,  sur  la  Contracture  permanente  des  hemiplegiques,  E.  Brissaud, 
Paris,  1380. 

*  Archiv.  fur  Psychiatrie  viii.  Band  3  Heft. 

*  Centralblatt  fiir  Med.  Wissen,  1878,  quoted  by  Brissaud. 


CEREBRAL    HEMORRHAGE. 


101 


It  would  be  going  into  the  subject  to  the  extent  of  neglecting  those  of 
greater  importance  were  I  to  do  else  than  present  the  conclusions  drawn 
by  modern  observers.  One  of  Brissaud's  plates  shows  the  contraction 
on  the  healthy  and  contracted  sides.  The  upper  irregular  line  gives  the 
contraction,  the  lower  line  the  time  tracings,  and  the  time 'of  exci- 
tation. 

Fi^.  14. 


Hemiplegia  with  contracture.    Reflex  on  sound  side.  Time  of  reflex  40-thousandths. 
TRACINGS  OF  PATELLAR  TENDON-REFLEX. 


Fig.  15. 


i' ■■■Imii 


''l '  1 1 ' '  "  'I  "  "  '"'-■^"  1 1  ll 


Hemiplegia  with  contracture.   Affected  side.  Time  of  reflex  36-thousandths. 

Causes. — Any  agency  which  favors  a  degeneration  of  cerebral  vessels 
leads  to  the  occurrence  of  hemorrhage  such  as  I  have  just  described.  The 
list  of  such  causes  is  therefore  a  long  one.  Among  the  many  formidable 
diseases,  leading  to  that  which  forms  the  present  subject  are  those 
of  the  heart  and  kidneys.  Hypertrophy  of  the  left  ventricle,  Bright's 
disease,  and  local  disease  of  the  arteries  with  deposits  of  atheromatous  mat- 
ter, or  obliteration  of  vessels  by  softening,  pressure  made  by  tumors,  and 
through  other  diseases  of  the  brain,  may  be  mentioned  as  influencing  the 


102         DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

causation  of  cerebral  hemorrhage.  Cerebral  hemorrhage  is  an  affection  of 
advanced  life,  though  cases  are  on  record  among  children.  A  careful 
inspection  of  the  records  of  a  great  many  cases  discloses  the  fact  that  the 
majority  are  between  fifty  and  sixty.  With  the  advance  of  life  and  cor- 
responding impairment  of  vitality,  the  arteries  become  rigid,  the  heart  hy- 
pertrophied,  and  the  general  vascular  system  undergoes  important  changes. 
I  have  already  alluded  to  the  annular  and  hard  character  of  the  arteries ; 
the  arcus  senilis,  which  consists  of  a  small  whitish  circle  which  may  be  seen 
at  the  edge  of  the  cornea,  may  be  mentioned  in  addition  as  a  suggestive 
sign,  and  attention  may  be  called  to  the  degeneration  of  the  choroid. 
The  color  of  the  face  is  dusky  red,  and  many  of  the  capillaries  of  the  skin 
covering  the  cheeks  and  nose  are  quite  tortuous  and  dilated,  and  present 
minute  varicose  enlargements.  As  to  inheritance  of  an  apojilectic  ten- 
dency, I  fully  agree  with  Hughlings  Jackson,  that  the  only  heritage  trans- 
mitted from  father  to  son  is  the  liability  to  arterial  degeneration,  gout,  etc. 
This  exception  to  the  general  rule  is  somewhat  conspicuous,  for  the  here- 
dicion  of  many  convulsive  and  neuralgic,  as  well  as  the  trophic  diseases, 
is  a  well-established  fact,  and  has  long  been  recognized  as  an  important 
etiological  factor.  Cerebral  hemorrhage,  as  I  have  stated,  is  by  no  means 
confined  exclusively  to  adult  life.  Xumerous  observers  have  called  atten- 
tion to  cases  which  have  occurred  among  very  young  children,  though, 
in  these  instances,  injury  has  generally  produced  the  accident,  especially 
such  mechanical  causes  as  convulsions,  anaemia,  etc-  And  now  regarding 
the  predisposing  states  which  favor  the  rupture  of  a  vessel.  An  hypertro- 
phied  heart,  enlarged  by  overwork  in  forcing  the  overloaded  blood  which 
must  be  formed  when  the  kidneys  do  not  properly  act  as  eliminants,  is  the 
first  factor  of  the  disease.  With  this  condition  of  affairs  the  small  vessels 
must  necessarily  be  subjected  to  abnormal  strain,  and  consequently  under- 
go such  changes  as  thickening  or  aneurismal  dilatation,  or  even  actual 
destruction.  The  arterial  changes,  of  which  I  will  more  fully  speak  when 
we  come  to  consider  the  pathology  of  the  disease,  are  fatty  degeneration, 
aneurismal  dilatation,  and  calcification.  These  conditions  are  produced 
by  alcohol,  and  improper  diet,  such  as  continued  indulgence  in  fatty  food. 
A  sedentary  life,  connected  with  great  and  protracted  intellectual  strain, 
as  well  as  such  diseases  as  rheumatism,  syphilis,  and  other  chronic  mala- 
dies, enter  the  field  as  predisposing  causes.  Season  appears  to  have  some 
influence  in  the  production  of  cerebral  hemorrhage,  the  majority  of 
cases  occurring  in  winter.  As  to  exciting  causes,  their  name  is  Legion. 
Straining  at  stool,  coition,  violent  muscular  effort  of  any  kind,  the  indul- 
gence in  stimulants,  and  in  fact  any  agency  which  either  promotes  an  ab- 
normal blood  supply  to  the  brain,  or  prevents  its  return,  will  have  the 
effect,  should  there  be  disease  of  the  vessels,  of  producing  rupture.  I 
have  taken  from  my  case-book  data  showing  the  causes  in  a  number  of 
cases,  which  in  some  cases  preceded  the  actual  hemorrhage  by  some  hours : 

Lifting  a  heavy  weight,  or  other  muscular  effort 12 

Excitement  (alarm  of  fire) 1 


CEREBRAL    HEMORRHAGE.  103 

Violent  exercise  in  drawing  water 1 

Falls 4 

Fright 3 

Thrown  down  by  husband 1 

Head  injuries 8 

Straining  at  stool ■ 2 

No  history  of  cause 20 

52 

Time  of  Attach. — At  night,  in  30  cases ;  during  the  day,  in  22  cases. 

The  fact  that  the  large  proportion  of  these  attacks  occur  at  night,  is  an 
interesting  one.  They  were  mostly  hospital  patients,  and  some  were  irre- 
sponsible ;  so,  of  course,  their  statements  are  to  be  taken  with  allowance. 
One  woman  said :  "  I  awoke  in  fright,  and  in  attempting  to  rise  found 
I  was  unable  to  do  so."  It  is  probable,  therefore,  that  the  condition  was 
dependent  upon  disturbed  cerebral  circulation  connected  with  nightmare  ; 
nearly  every  one  of  these  thirty  patients  found  that  they  were  paralyzed 
only  when  they  awoke  in  the  morning,  and  attempted  to  get  out  of  bed. 
Exposure  to  the  sun's  rays,  and  the  stoppage  of  any  flux  that  is  either 
normal  or  pathological,  are  often  sufficient  to  produce  an  attack,  and  as 
an  example  of  the  latter  hemorrhoidal  bleeding  may  be  mentioned. 

Hemiplegia  may  be  a  result  of  variola ;  and  the  following  case,  in  which 
epilepsy  and  hemiplegia  dated  from  smallpox,  possesses  much  interest. 
The  paralysis  was  due  undoubtedly  to  an  epileptic  seizure,  during  which 
some  vessel  was  ruptured. 

M.  J.  T.,  35  years,  born  in  New  York;  no  occupation;  entered  the 
Epileptic  and  Paralytic  Hospital  Feb.  11,  1870.  Mother  died  of  con- 
sumption ;  sister  had  epilepsy.  First  fits  appeared  at  the  age  of  five  years ; 
came  on  about  three  months  after  the  attack  of  smallpox ;  hemiplegia  of 
the  right  side  came  on  at  the  same  time,  she  believes,  as  the  epilepsy. 
Before  the  convulsions  she  had  cramps  in  the  paralyzed  arm  and  hand, 
and  a  feeling  of  dizziness ;  the  attacks  occur  most  frec[uently  in  the  day- 
time, three  or  four  together,  and  recur  once  in  three  or  four  weeks.  But 
shortly  before  her  admission  she  had  them  nearly  every  day.  Circum- 
ference of  skull,  201  inches;  antero-posterior  measurement,  12  inches; 
transverse,  1 3  inches  ;  memory  good,  mind  rather  weak  ;  speech  good,  sight 
good,  hearing  fair  with  left  ear  ;  cannot  hear  with  right  ear,  even  when 
the  watch  is  pressed  against  it,  Sensibility  to  pinching  and  pricking  ap- 
pear entirely  abolished  on  the  right  side  from  head  to  foot.  Drags  right 
leg  in  walking ;  has  but  little  use  of  right  arm  and  hand,  the  muscles  of 
which  have  a  tendency  to  spasmodic  contraction  ;  temperature  somewhat 
diminished  on  right  side  ;  appetite  fair  ;  bowels  rather  costive.  Menstru- 
ated at  13  years,  and  has  been  regular  since. 

Present  condition,  June  1,  1876: — 

Memory  appears  to  be  very  good  ;  and  the  fits  have  decreased  in  seve- 
rity and  in  number.  Had  but  two  attacks  last  month ;  none  at  night. 
Has  hsemoptysis  sometimes  before  the  attack,  and  an  aura  of  about  a 


104         DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

minute's  duration  ;  flexor  of  muscles  of  right  hand  is  contracted  :  thumb 
is  turned  again,  so  that  its  inner  part  touches  the  under  part  of  the  index 
finger;  lastly,  the  whole  hand  is  somewhat  drawn  up,  and  lies  in  her  lap 
with  the  palmar  surface  up.  When  directed  to  put  hand  up  to  shoulder, 
it  shakes  right  and  left ;  this  shaking  is  very  violent,  but  only  so  when  she 
makes  voluntary  movement.  It  is,  however,  entirely  quiet  while  in  her 
lap.  Has  the  irregular  heraiplegic  gait ;  protrudes  her  tongue  straight  ; 
eyesight  good  ;  hears  perfectly  well.  There  is  facial  paralysis  (periphe- 
ral) on  the  side  opposite  the  hemiplegia,  but  no  ptosis. 

As  an  illustration  of  a  curious  case  of  cerebral  hemorrhage,  Eulenburg  ^ 
relates  the  ease  of  a  switch-tender  who,  during  a  heavy  thunder  storm, 
inserted  an  iron  key  in  the  lock  of  a  switch  signal.  He  was  suddenly  de- 
prived of  power,  and  fell  to  the  ground.  After  an  hour  or  two,  when 
sufficiently  revived  by  the  rain,  he  dragged  himself  to  a  neighboring  sta- 
tion.  He  was  paralyzed  on  the  left  side. 

Morbid  Anatomy  and  Pathology. — A  vessel  impaired  by  disease, 
and  subjected  to  even  the  normal  blood  pressure,  will  very  soon  sufter 
changes  in  its  calibre,  insignificant  perhaps  at  first,  but  afterwards  far 
more  serious,  but,  when  the  blood  pressure  is  abnormal,  and  a  force  is 
exerted  which  the  resilient  character  of  the  vessels  enables  them  to  with- 
stand in  the  healthy  state  ;  the  weakened  portion  gives  way,  and  the  brain- 
substance  in  the  neighborhood  is  subjected  to  dangerous  pressure.  The 
character  of  the  loss  of  function  depends  very  much  upon  the  importance 
of  the  vessels  and  their  areas  of  distribution.  The  middle  cerebral  artery 
is  especially  liable  to  rupture,  being  in  direct  communication  with  the 
left  side  of  the  heart;  consequently,  the  corpus  striatum,  optic  thalamus, 
and  parts  supplied  by  this  artery,  suffer  injury.  The  other  large  vessels 
follow  next,  and  may  be  affected  in  various  parts  of  their  course. 

Such  strides  have  been  made  in  the  study  of  cerebral  anatomy  and 
physiology  during  the  past  four  or  five  years  that  it  is  necessary  that  the 
whole  subject  of  nervous  pathology  should  be  viewed  in  a  new  light. 
New  interest  began  with  the  researches  of  Jackson,  Hitzig,  Fritsch  and 
Ferrier,  and  has  since  the  discovery  of  the  cortical  centres  been  greatly 
increased  by  the  valuable  researches  of  Flechsig,  Meynert,  Huguenin, 
Charcot  and  a  host  of  others.  In  the  matter  of  central  localization  it 
behooves  us  to  study  the  relations  of  the  cortical  psycho-motor  centres 
and  the  so-called  jjyramidal  trad  comprising  the  descending  fibres  which 
run  between  the  nuclei  of  the  corpus  striatum,  and  the  optic  thalamus,  as 
the  internal  capsule,  subsequently  extending  backwards  and  downwards 
as  the  peduncle  (crus)  and  passing  to  the  other  side  of  the  body,  more 
or  less  fully  in  the  pyramidal  decussation. 

The  sensory  ganglia,  and  the  fibres  passing  from  thence  downwards, 
and  the  connection  of  the  bulb  with  the  cerebrum,  come  in  also  for  con- 
sideration. It  will  be  only  possible  in  this  limited  space  to  consider  the 
anatomical  relation  and  physiological  functions  of  these  parts  so  far  as 
they  concern  the  occurrence  of  lesions. 

1  Berliner  Klin.  Woch.,  April  26,  1875. 


CEREBRAL    HEMORRHAGE. 


105 


The  cortex-cerebri  has  been  found  to  be  the  seat  of  well  limited 
centres,  which  when  subjected  to  irritation  from  disease  or  mechanical 
injury,  lose  the  function  of  localized  sensory  and  motor  innervating 
power.  The  gray  matter  of  the  cortical  motor  region  is  found  to  be 
peculiarly  rich  in  large  giant  cells  such  as  are  met  with  in  the  anterior 
gray  cornuse  of  the  spinal  cord,  and  by  some  authors  are  supposed  to  be 
identical  with  the  latter.  The  more  important  of  these  centres  are 
motor,  and  have  been  more  or  less  appropriately  called  psycho-motor 
centres,  and  those  of  greatest  significance  are  to  be  found  upon  either  side 

Fiff.  16. 


Cortical  Centres.    (Morel.) 


of  the  Eolandic  fissure  in  the  ascending  parietal  and  frontal  convolu- 
tions, and  preside  for  the  most  part  over  the  movements  of  the  face  and 
its  parts  and  the  limbs  of  the  opposite  side  of  the  body.  There  are  more 
posteriorly  other  centres  which  have  a  sensory  function.  At  the  angular 
gyrus  (pli  Courbe),  for  example,  a  visual  centre  is  found  which  fills  a 
prominent  office  in  the  regulation  of  visual  correction,  while  other  limited 
regions  exist  which  undoubtedly  play  an  important  part  as  centres 
for  the  sense  of  audition,  taste  and  smell. 

The  excellent  plate  (Fig.  16)  from  Morel's  Atlas  will  enable  the 
reader  to  appreciate  the  action  of  the  cortical  centres.  It  is  based  upon 
the  investigations  of  Ferrier. 

1-  Speech  centre  of  Broca.     Posterior  part  of  third  frontal  convolution. 

2.   Centre  for  the  movements  of  the  upper  extremities,  situated  on  the 


106         DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

ascending  frontal  and  parietal  convolution  circle  (over  the  middle  of  the 
fissure  of  Rolando). 

3.  Centre  for  the  movements  of  the  lower  extremities.  Situated  at  superior 
extremity  of  ascending  parietal  convolution. 

4.  Centre  for  movements  of  head  and  neck.  Over  posterior  extremity, 
or  foot  of  superior  frontal  convolution. 

5.  Centre  for  movements  of  lips.  Posterior  extremity,  or  foot  of  the 
middle  frontal  convolution. 

6.  Centre  for  movements  of  eyes.     Angular  gyrus  of  parietal  lobe. 
These  are  in  the  main  the  important  psycho-motor  centres,  although 

they  are  capable  of  modification,  and  I  would  refer  the  reader  for  further 
details  to  Ferrier's  admirable  book.  ^ 

The  sensory  centres,  though  more  difficult  to  define,  have  occasionally 
been  found  to  be  the  seat  of  disease,  lesions  beiug  connected  with 
limited  loss  of  function.  The  centre  of  vision  may  be  located  in  the 
supra-marginal  lobule  and  angular  gyrus  in  proximity  to  that  centre 
concerned  in  the  movements  of  the  eyes,  though  it  should  not  be  con- 
founded with  an  anterior  centre  situated  ujDon  the  superior  and  middle 
frontal  convolutions,  Avhich  control  lateral  movement  of  the  eyes  and 
dilation  of  pupils. 

The  centre  for  hearing  is  located  in  the  superior  tempero-sphenoidal 
convolution.  The  centre  for  smell  has  been  found  by  Ferrier  in  the 
subiculum  cornua  Ammonis,  and  irritation  of  this  region  is  associated 
with  some  closure  of  the  nostrils.  The  centre  of  taste  is  supposed  by  this 
author  to  be  located  in  close  proximity  to  the  last  mentioned  centre. 
Many  hundred  observations  have  been  collected  by  Charcot  and  Lan- 
douzy,  Pitres,  Seguin  and  a  host  of  foreign  and  American  observers,  and 
most  of  them  have  a  bearing  confirmatory  upon  this  theory,  although  it 
must  be  confessed  that  the  large  majority  of  collected  cases  j^resent  mul- 
tiple or  extensive  lesions,  which  too  often  cloud  the  diagnosis.  The 
published  cases  prove  in  several  ways,  and  first  that  cortical  alterations 
in  places  found  by  experiment  not  to  be  the  seat  of  psycho-motor 
centres  are  not  followed  by  hemiplegia,  and  this  is  shown  by  the  cases  of 
Pitres.  ^  Two  cases  are  presented  by  Pitres,  one  of  softening  of  the 
inferior  parietal  lobule  and  sphenoidal  convolutions,  and  the  other  of 
abscesses  of  the  occipital  lobe  without  hemiplegia,  while  other  cases 
brought  forward  by  him  show  the  connection  of  hemiplegia  with 
cortical  softening  of  the  ascending  parietal  convolution  on  one  side,  and 
aphasia  with  destruction  of  the  third  frontal  convolution. 

In  cases  where  autopsies  have  been  made  it  has  been  found  that  a  de- 
generation of  the  motor  fibres  passing  from  this  area  of  cortical  centres 
had  commonly  taken  place,  and  that  such  "secondary  degeneration" 
had  extended  down  into  the  cord  involving  certain  parts  of  the  lateral 
columns,  to  be  alluded  to  hereafter,  and  this  secondary  trouble  was 

^  The  Functions  of  the  Brain.     London,  1876. 

^  Progres  Medicale,  August  7,  1880,  and  Kevue  Mensuelle. 


CEREBRAL    HEMORRHAGE. 


107 


found  in  some  cases  disconnected  from  any  special  lesion  of  the  so-called 
motor  ganglia,  at  the  base  of  the  brain,  proving  beyond  doubt  that  the 
cortical  psycho  motor  zone  was  that  primarily  affected. 

The  disturbances  of  motility  observed  in  connection  with  such  cortical 
degeneration  have  been  found  to  be  of  two  kinds,  spasm  and  paralysis 
existing  together  or  apart,  the  latter  being  but  an  extended  stage  of  the 
former ;  and  the  interesting  series  of  cases  originally  brought  forward  by 
Hughlings  Jackson,  who  may  be  said  to  be  the  father  of  central  localiza- 
tion, give  to  the  matter  an  importance  it  really  never  has  had  accorded 
to  it.  It  is  the  opinion  of  both  Jackson  and  Brown-Sequard,  both  of 
whom  have  never  been  inclined  to  look  upon  the  subject  in  anything 
like  a  narrow  way,  that  the  psycho-motor  centres  are  not  confined  alone 
to  the  cortex,  but  exist  throughout  the  brain  as  a  complex  system. 

My  own  experience  has  led  me  to  adopt  this  view,  especially  as  I  have 
seen  cases  in  which  the  cortical  centres  of  Ferrier  were  involved  and  in 
which  the  only  disturbances  of  motility  were  hyperkinetic,  such  as 
localized  spasms;  and  it  would  seem  to  me  that  the  destruction  of  the  cor- 
tical centres  resulted  more  often  in  an  interruption  of  inhibitory  control 
than  in  intrinsic  and  primiry  abolition  of  motor  power.  There  are 
numerous  cases  of  cortical  epilepsy  in  which  no  paralysis  occurs,  al- 
though the  limitation  of  spasm  to  the  member  innervated  by  its  particular 
cortical  centre  should  always  suggest  the  diagnosis.  The  occurrence  of 
spasm  in  a  monoplegic  limb,  that  is  to  say  a  limb  the  seat  of  paralysis 
other  parts  being  unaffected,  is  pretty  certain  to  bear  evidence  of  degenera- 
tion of  a  particular  convolution. 


(Charcot.' 


When  a  large  extent  of  cortical  territory  is  destroyed  we  find  a  pecu- 
liar and  extensive  degeneration,  which  takes  a  well-defined  downward 
course,  as  may  be  seen  from  reference  to  Charcot's  admirable  plate 
(Fig.  17).  The  zone  which  includes  the  psycho-motor  centres 
above,  and  the  inferior  motor  tracts,  may  be  shown  by  a  vertical  cut 
which  separates  the  hemispheres.     A.  represents  the  caudate  nucleus ; 


108         DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

B,  the  lenticular  nucleus ;  C,  the  oiJtic  thalamus,  while  between  them 
passes  the  collection  of  fibres  known  as  the  internal  capsule.  The  rela- 
tion of  the  nervous  tracts  with  the  convolutions  above  and  the  basal 
ganglia  below  is  also  shown  in  the  diagram.  D  represents  the  para- 
central lobe,  which  has  been  found  to  be  the  most  important  psycho- 
motor region  ;  E,  the  ascending  frontal  convolution ;  F,  the  ascending 
parietal ;  G,  the  fissure  of  Rolando.  The  various  parts  of  the  internal 
capsule  are  represented  by  H,  K,  and  L.  H  represents  the  internal 
capsule ;  K,  the  "  pyramidal "  region  of  the  posterior  segments  of  the 
internal  capsule,  and  L  the  part  concerned  in  sensation.  The  anatomical 
arrangement  of  the  internal  capsule  may  be  diagrammatically  represented 
by  the  tract  of  white  represented  by  the  letters  H  and  K  in  the  above 
diagram.  It  will  be  noticed  that  these  tracts  unite  at  an  obtuse  angle, 
which  latter  by  the  Germans  and  French  is  known  as  the  "knee  of  the 
internal  capsule."  The  anterior  segment  of  this  collection  of  fibres  contains 
those  which  are  essentially  motor,  while  the  posterior  are  sensory.  The 
knee  contains  fibres  which  terminate  in  the  bulb  and  have  a  con- 
nection with  some  of  the  great  nerves  of  the  medulla  concerned  in  the 
voluntary  innervation  of  the  tongue  and  other  parts  of  the  face. 

In  the  diagnosis  of  cerebral  disease  it  is  well  that  we  should  bear  in 
mind  the  relation  of  cerebral  ganglia  and  their  commissural  connections, 
and  a  transverse  section  of  the  brain,  when  studied  microscopically  and 
otherwise,  will  enable  us  to  see  that  not  only  are  the  two  hemispheres 
connected  together,  but  the  various  gray  segments  are  brought  into  rela- 
tion by  diiferent  sets  of  fibres  which  may  be  briefly  enumerated  as 
follows:  Fibres  which  connect  the  optic  thalamus  and  the  lenticular  nu- 
cleus and  the  caudate  nucleus  with  the  periphery  of  the  brain ;  fibres 
connecting  the  lenticular  nucleus  with  the  gray  matter  of  the  sphenoidal 
lobe.  These  internal  intercommunicating  fibres  form  a  system  by  them- 
selves, Avhile  a  second  set  of  fibres  having  a  direct  course,  (peduncular 
fibres)  serve  for  the  direct  reception  and  transmission  of  sensorial  impres- 
sions and  motor  impulses. 

After  the  fibres  of  the  internal  capsule  reach  a  lower  and  more  posterior 
level  ihey  unite  in  the  peduncle,  which,  according  to  Brissaud  and  others, 
contains  four  sets  of  fibres,  each  having  a  well  defined  ofiice  and  correspond- 
ing with  the  arrangement  in  the  internal  capsule.  They  are  as  follows  : 
1.  A  posterior  bundle,  the  ofiice  of  which  is  the  conduction  of  sensory 
impressions.  2.  A  bundle  composed  of  fibres  especially  engaged  in  the 
motor  innervation  of  the  trunk  and  limbs.  3.  A  small  bundle  of  fibres 
connected  with  the  angle  (genou)  of  the  internal  capsule,  and  which  con- 
tain motor  fibres  connected  with  the  bulb '  and  are  concerned  in  voluntary 
movements  of  the  face,  and  tongue.  4.  An  internal  bundle  of  fibres 
going  to  the  bulb. 

Evidences  of  secondary  degeneration,  after  certain  cerebral  lesions  in- 

^Loc.  cit. 


CEREBEAL     HEMORRHAGE.  109 

volving  tlie  motor  track  are  best  seen  in  the  inner  and  middle  thirds  of 
the  peduncle  and  sometimes  occupy  a  pyramidal  character  the  base  being 
anteriorly. 

The  course  of  the  motor  fibres  has  been  studied  most  fully  by  Flechsig 
in  the  embryo,  and  he  has  materially  overturned  the  old  views — notably 
those  of  Brown-Sequard  in  regard  to  the  total  decussation  of  fibres  in 
the  pyramids.  Flechsig  has  found  that  the  extent  of  decussation  is  very 
variable,  and  that  in  the  great  number  of  cases  there  is  by  no  means  total 
decussation.  This  will  explain  the  possibility  of  hemiplegia  upon  the 
same  side  as  the  cerebral  lesion  in  individuals  in  whom  the  pyramidal 
decussation  is  imj^erfect. 

The  study  of  sensory  disturbances  following  brain  lesions  has  not  kept 
pace  with  that  of  the  localization  of  motor  troubles.  Certain  facts  have 
been  clearly  brought  forward,  however,  and  the  most  important  of  these 
is  that  injury  of  the  posterior  segments  of  the  internal  capsule  is  produc- 
tive of  hemianesthesia,  Veyssiere^  was  the  first  to  make  this  clear,  and 
Charcot,  Ferrier  and  others  have  since  proved  the  connection  of  such 
unilateral  anaesthesia  with  loss  of  smell  and  vision  upon  the  same  side. 
Injury  of  the  convolutions  about  the  fissure  of  Rolando  has  not  been  so 
far  found  to  be  followed  by  general  aniesthesia,  although  according  to 
Ferrier  the  occipital  convolutions  seem  to  some  extent  to  possess  sensorial 
functions.  The  optic  thalamus  has  undoubtedly  much  to  do  with  sensory  in- 
nervation, and  Friedrich  and  Charcot  have  both  found  that  hemorrhage 
or  tumor  in  regions  adjacent  to  the  posterior  part  of  this  organ  produced 
anaesthesia,  and  in  certain  cases  of  epilepsy,  with  peculiar  sensory  aur^e. 
Hammond  has  regarded  the  optic  thalamus  as  the  seat  of  the  lesion. 

The  blood  supply  of  the  brain  is  derived  from  two  systems  of  vessels,  a 
basal  or  central,  and  a  cortical  or  external. 

It  has  been  proved  by  Duret  and  others  that  there  is  no  distal  connec- 
tion between  these  two,  and  that  the  central  arteries  as  a  rule  supply  but 
a  limited  territory.  The  importance  of  the  central  arteries,  which  are 
much  larger  than  those  supplying  nutrition  to  the  cortical  gray  matter, 
is  derived  from  the  fact  that  in  rupture  or  disease  much  more  profound 
and  sudden  symj^toms  occur  than  when  the  others  are  affected,  because  of 
the  existence  of  anastomoses  in  the  latter.  Charcot  alludes  to  several 
facts  which  in  this  connection  should  be  borne  in  mind  in  the  localiza- 
tion of  symptoms.  1.  Vascular  lesions  upon  the  surface  of  the  brain 
and  hemorrhages  as  a  consequence  do  not  occur  so  often  as  in  the  sub- 
stance of  the  brain,  for  the  reason  that  the  cortical  vessels  are  protected 
in  their  course  by  their  dura  mater  and  other  coverings,  that  they  are 
smaller,  and  are  not  subjected  to  so  much  pressure  as  those  of  the  cen- 
tral system. 

2.  Proximity  of  the  arteries  of  the  central  system  to  the  heart — their 
simple  arrangement  and  liability  to  sudden  pressure  predisposes  to  acci- 

^Kecherclies  Clinique  et  Experimeutales,  sur  rhemianEestliesie.    Paris,  1874. 


110         DISEASES    OF    THE     CEREBRUM    A>'D    CEREBELLU 


M. 


dents  in  deeper  parts,  and  for  this  reason  central  or  deep  hemorrhages  are 
serious. 

A  reference  to  Fig.  18  will  enable  the  reader  to  appreciate  the  vessels 


(Charcot.) 
Fig.  18.,  (Charcot).  Central  vascular  supply.  A.  Territory  of  Sylvian  artery.  B.  Ter- 
ritory of  anterior  cerebral  artery.  C.  Territorj'  of  posterior  cerebral  artery.  D.  External 
wall.  E  E  E  E.  Internal  capsule.  F.  Walls  of  Trigonal  arches.  G.  Lateral  ventricle.  H.  Caudate 
nucleus.  I.  l.«land  of  Rail.  J.  External  arteries  of  corpora  striata.  L.  Sylvian  artery.  M.  Internal 
carotid.  N.  Gray  substance  of  third  ventricle.  0.  Optic  chiasm.  P.  Section  of  optic  nerve.  Q. 
Lenticular  nucleus.  R.  External  capsule.  S.  Anterior  cerebral  artery.  Vascular  areas  are  indi- 
cated bv  dotted  lines. 


concerned  in  the  supply  of  the  central  ganglia.  The  Sylvian  or 
middle  cerebral  artery  is  the  most  important  of  these,  and  it  will  be 
found  that  when  it  leaves  the  internal  carotid  it  sends  up  central 
branches  to  supply  a  part  of  the  caudate  nucleus,  the  entire  lenticular 
nucleus,  theiuternal  capsule  and  a  part  of  the  optic  thalamus.  It  will  be 
seen  by  the  dotted  lines  that  nearly  two-thirds  of  the  hemisphere  is  sup- 
plied by  this  important  vessel  and  its  central  and  cortical  branches.  The 
posterior  cerebral  artery  furnishes  nourishment  to  the  parts  of  the  optic 
thalamus  not  supplied  by  the  Sylvian — namely,  the  external  and  posterior 
parts.  It  also  supplies  the  tubercula  quadrigemina  and  the  crura  cerebri. 
The  anterior  cerebral  artery  is  concerned  only  in  the  supply  of  a  small 
part  of  the  caudate  nucleus. 

Fig.  19  shows  the  course  of  the  middle  cerebral  artery  which  .sends  off 
branches  to  supply  the  cortical  portions  of  the  brain  after  it  fulfils  an 
equally  important  office  in  supplying,  at  the  base,  central  vessels  to  the 
ganglia. 

The  cortical  branches  of  this  vessel  are  quite  large,  and  are  four  in 


CEREBRAL    HEMORRHAGE. 


Ill 


number.  These  severally  supply  the  frontal,  parietal,  and  sphenoidal  con- 
volutions. The  island  of  Reil  is  supplied  by  ajarge  branch  which  leaves 
the  main  artery  when  it  divides  into  the  large  terminal  branches.  The 
four  vessels  alluded  to,  break  up  into  smaller  or  secondary  arteries  at 
higher  points,  such  secondary  arteries  supplying  a  small  track  of  convo- 
lution. There  are  still  "  tertiary  branchlets  "  which  anastomose  with 
each  other  forming  arborescent  ramifications — though  Duret  does  not  agree 
with  Charcot  and  others  regarding  this  fact. 

Fig.  19. 


IVi     N    0 

(Charcot.) 

Cortical  branches  of  Sylvian  artery.  ABC.  Frontal  CoNvoLtrTiONS.  D.  Ascending  FsoNTAt 
Convolution.  E.  Ascending  Parietal  Convolxttion.  H.  Infra-parietal  convolution.  G.  Supra- 
Parietal  Lobule.  L  Occipital  Lobe.  J.  Trunk  of  Sylvian  Artery.  K.  Perforating  branches  of 
central  gray  ganglia.  L.  Ext.  and  superior  frontal  branches.  M.  Ascending  frontal  artery 
N.  Ascending  parietal  artery.    O.  Parieto-.sphenoidal  and  sphenoidal  arteries. 

Upon  the  surface  of  the  convolutions  we  find  nutrient  arteries  of  small 
size  and  capillary  character,  which  are  branches  of  the  "  tertiary  branch- 
lets."  These  arteries  enter  the  cortex  at  a  right  angle  with  its  external 
surface  and  are  called  long  and  short,  with  reference  to  their  extent  of 
penetration.  The  lo7ig  or  "  medullary  "  arteries,  are  terminal  vessels  of 
the  tertiary  branchlets  and  pass  perpendicularly  into  the  gray  cortex  and 
white  substance,  but  have  no  connection  ivith  the  cerebral  arteries  below, 
while  the  short  cortical  or  nutrient  arteries,  which  also  come  from  the 
tertiary  branchlets  or  ramifications,  rarely  extend  deeper  than  the  corti- 
cal gray  matter.  The  only  difference  in  the  character  of  the  two  forms 
of  nutrient  arteries,  for  they  have  a  common  origin,  is  that  they  extend 
to  different  distances  from  the  cortical  periphery,  and  while  one  supplies 
chiefly  one  form  of  nervous  matter,  (the  white)  the  other  nourishes  the 


112         DISEASES    OF    THE    CEREBRUJI    AXD    CEREBELLUM. 

gray.  It  will  be  found  that  a  sort  of  arborization  or  net-work  is  found  in 
the  gray  matter,  which  depends  chiefly  upon  communicating  arteries 
from  the  short  vessels  with  an  occasional  reinforcement  from  the  lo)iff, 
and  also  that  the  terminal  branches  of  the  large  trunks  are  entirely 
distinct  from  those  arising  from  a  lower  level,  and  which  enter  the 
brain  at  a  basal  point  to  become  central  arteries. 

Other  cortical  parts  of  the  'train  are  supplied  chiefly  by  branches  of 
the  anterior  cerebral,  and  posterior  cerebral  arteries. 

The  pathological  course  of  cerebral  hemorrhage  is  the  following :  I .  The 
stage  of  preparation,  during  which  the  arteries  undergo  the  changes  already 
spoken  of.  2.  The  operation  of  an  exciting  cause,  the  rupture  of  the  ves- 
sel, the  injury  of  the  nervous  substance,  and  the  formation  of  the  clot. 
3.  Death  ;   absorption,  or  limitation. 

Bouchard^  and  Charcot  both  affirm  that  cerebral  hemorrhage  is  always 
dependent  upon  a  peculiar  kind  of  disease  of  the  vessels.  This  diseased 
condition  consists  of  a  studding  over  with  minute  aneurismal  dilatations 
which  have  been  called  by  them  "  miliary  aneurisms."  These  arise  from 
a  primary  degeneration  of  the  outer  coat  of  the  vessel,  secondarily 
sclerosis,  and  finally  atrophy,  of  the  muscular  coat  and  dilatation.  Of 
sixty-five  cases"  of  cerebral  hemorrhage,  they  found  miliary  aneurism  in 
every  instance.  Both  of  these  authors  consider  the  vascular  change  to 
be  difterent  from  that  of  atheroma,  which  begins  in  the  inner  coat.  These 
appearances  are  confined  to  the  brain,  and  exist  where  there  is  no  evi- 
dence of  atheroma  to  be  found  in  any  other  part  of  the  body.  Notwith- 
standing the  fact  that  these  views  are  endorsed  by  such  men  as  Meynert, 
Bastian,  and  others,  there  are  many  observers  who  consider  miliary 
aneurisms  to  be  due  only  to  careless  manipulation,  or  to  be  identical  with 
the  "  hyaline  degeneration"  of  Gull  and  Sutton  which  is  found  in  other 
localities. 

Dr.  Barlow "  has  presented  a  case  which  fully  demonstrates  that  cere- 
bral embolism  may  produce  a  conditon  of  the  vessels  which  leads  to  the 
formation  of  aneurisms,  first  causing  local  arteritis  and  weakening  of  the 
wall  of  the  vessel.  In  this  case  (that  of  a  boy  aged  ten  years)  there 
was  right  and  afterwards  left  hemiplegia,  and  aortic  regurgitation.  The 
autopsy  revealed  "  cortical  softening  on  each  side  of  the  lower  part  of 
the  ascending  frontal  and  the  posterior  parts  of  the  second  and  third 
frontal  convolutions.  The  clue  to  this  condition  was  found  in  the  middle 
cerebral  arteries.  On  both  sides  these  vessels  were  diseased  at  the  spot 
where  the  fine  branches  were  given  oflT  over  the  island  of  Reil  for  the 
supply  of  the  cortex.  Of  these  branches  on  both  sides,  the  one  supplying 
Bi'oca's  convolution  and  the  one  supplying  the  ascending  frontal  were 
also  diseased.  There  waa  no  aneurism  to  be  discovered  anywhere,  but 
the  walls  of  these  vessels  presented  many  small  calcified  nodules  obvious 
to  touch  and  sight  "     This  calcification  was  not  noticed  in   any  other 

^  Archives  de  Physiol.,  1868. 

2  Brit.  Med.  Journal,  April  7,  1877,  p.  372. 


CEREBRAL    HEMORRHAGE.  113 

vessel  in  the  body,  and  emboli  bad  lodged  in  the  spleen  and  kidneys. 
In  Goodhart's  cases  actual  aneurism  had  followed  the  embolism,  and 
Dr.  Barlow's  case  demonstrates  that  there  is  a  primary  weakening. 

Durand-Fardel  ^  found  that  of  32  cases  the  arteries  were  only  healthy 
in  9  cases,  while  in  21  they  were  thickened,  and  in  2  ossified. 

AndraP  found  that  of  32  cases  the  arteries  were  apparently  healthy 
in  but  4. 

These  miliary  aneurisms  have  been  said  to  be  due  to  "  periarteritis,"  but 
it  cannot  be  denied  that  a  large  proportion  of  cases  of  renal  and  heart 
disease  produce  modifications  in  blood  pressure,  which  would  account  for 
the  rujiture  of  the  vessel  without  any  primary  inflammatory  condition. 

Fig  20. 


Miliary  Aneurisms. 

I  have  repeatedly  seen  miliary  aneurisms,  and  must  confess  that  they 
appeared  to  depend  upon  some  organic  change  which  extended  over  a 
considerable  space  of  time. 

Zenker  difiers  from  Charcot  and  Bouchard,  and  considers  the  internal 
coat  to  be  that  which  is  first  attacked.  "When  miliary  aneurism  exists,  it 
is  generally  in  conjunction  with  either  gout,  cancer,  tubercule,  leucocythe- 
mia,  or  other  conditions,  when  leucocytes  may  jDass  into  the  cerebral  ves- 
sels in  large  number.  In  old  drunkards  and  general  paralytics  this  vascular 
change  is  not  an  uncommon  one.  In  regard  to  atheroma  there  have  been 
many  cases  brought  forward  where  this  appearance  was  so  constant  as  to 
gain  recognition  as  one  of  the  chief  factors  of  the  cerebral  hemorrhage.  An 
atheromatous  artery  contains  deposits  of  a  firm,  semi-fatty  nature,  between 
its  inner  and  middle  coats.  At  an  advanced  stage  the  deposit  is  more 
calcareous  and  hard,  and  the  artery  may  be  sometimes  easily  broken  in 
two.     Occasionally  the  deposit  between  the  coats,  by  distension  considera- 

^  Traite  clinique  et  pratique  des  Maladies  des  Vieillards,  Paris,  1854,  p.  228. 
2  Clinique  Med.,  vol.  v. 


114         DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

bly  narrows  the  calibre  of  the  vessel,  and  in  this  way  forms  occlusion  at 
one  point  while  at  a  weaker  one  hemorrhage  takes  place.  The  veins  and 
capillaries  are  not  so  often  involved  as  the  arteries.  In  regard  to  the  seat 
of  cerebral  hemorrhages,  we  find  from  a  table  prepared  by  Rosenthal.^ 

rimes. 

In  the  corpus  striatum  alone 32 

"      nucleus  lentiformis  alone 20 

''      both  these  ganglia  combined 8 

"      corpora  striatum  and  optic  thalamus 7 

''      cent,  nucleus  and  other  parts  (centrum  seraiovale,  occipital  lobe, 

island  of  Reil,  pons  and  cerebellum) 6 

"      optic  thalamus  alone 20 

"         "  "         and  corp.  striat.  of  both  sides  (recent  hemorrhages 

and  old  cicatrices.) 2 

"        "      thalamus  and  lent,  nucleus  of  both  sides 3 

"      centrum  semiovale 3 

''     parietal  lobe 2 

Total 103 

It  may  be  stated  that  large  portions  of  both  hemispheres  are  de- 
stroyed without  serious  symptoms ;  but  when  we  approach  the  base  the 
danger  is  increased,  and  if  the  third  frontal  convolution  be  the  seat,  we 
find  a  very  decided  and  serious  result,  which  is  aphasia.  The  majority 
of  hemorrhages  are  in  or  about  the  optic  thalami  and  the  corpora  striata, 
together  or  singly,  and  if  they  be  extentive  the  ventricles  will  be  filled. 
If  the  hemorrhage  be  great,  pressure  may  be  made  on  the  opposite  side, 
or  the  blood  may  find  its  way  into  other  localities.  In  the  anterior 
lobes  the  effusion  is  generally  circumscribed,  but  from  this  site  it  may 
find  escape  into  the  lateral  ventricles.  In  the  ganglia  and  important 
parts  at  the  base,  the  hemorrhage  is  generally  small,  but  is  all  the  more 
serious  because  of  the  importance  of  the  parts  it  destroys.  This  is 
the  case  in  the  corpora  striata.  In  the  pons  and  medulla  any  con- 
siderable extravasation  is  followed  by  death  or  serious  trouble.  The  shape 
of  the  cavity  is  variable,  but  in  the  gray  matter  it  is  circumscribed,  and 
in  the  white  it  is  irregular  and  elongated. 

Parrot"  reports  34  cases  of  cerebral  hemorrhage  in  new-born  children. 
In  these  the  clot  was  found  at  the  inferior  part  of  the  brain  ;  sometimes 
on  the  right  side,  but  more  generally  on  both  sides. 

Should  the  patient  survive  the  apoplectic  attack,  and  die  subsequently 
of  some  other  disease,  the  cerebral  clot  will  probably  prove  to  be  well 
organized,  hard,  and  separated  from  the  brain-tissue  in  the  vicinity  by  a 
sclerosed  mass.  The  immediate  changes  are  the  following  :  At  the  end  of 
a  few  days  the  serum  is  absorbed,  leaving  the  solid  portion  as  a  gelatinous 
mass  ;  finally  the  clot  contracts,  becomes  yellow,  and  assumes  the  appear- 

'  A  clinical  treatise  on  the  diseases  of  the  nervous  svstem,  translated  by  L.  Putzel 
N.  Y.,  1879,  p.  38. 

-Arch,  de  Tocolowje,  1875. 


CEREBRAL    HEMORRHAGE.  115 

auce  I  have  alluded  to.  It  is  rare  that  an  old  clot  is  completely  absorbed, 
but  it  is  found  encysted  and  firm,  and,  perhaps,  has  produced  some  soften- 
ing. It  is  not  uncommon  to  find  more  than  one  clot  in  a  patient  who  has 
had  several  hemorrhages.  There  may  be  a  cyst  filled  with  thickened 
blood,  which  is  indicative  of  an  eiFusion  of  recent  occurrence,  and  there 
may  be  others  of  smaller  size,  in  different  stages  of  resolution.  Small 
aneurismal  dilatations  are  also  found,  while  local  patches  of  softening,  or 
cysts  filled  with  clear  serum,  are  not  rarely  present  at  the  same  time. 
Much  has  been  said  about  the  relation  of  decubitus  to  brain  lesions  ;  how- 
ever, there  does  not  seem  to  be  any  special  connection  between  disease  of 
certain  parts  of  the  brain  and  the  causation  of  bad  sores,  though  Joffroy  ^ 
has  reported  three  cases  in  which  acute  decubitus  was  found  with  lesions 
of  the  occipital  lobe  and  optic  thalamus  upon  the  opposite  side.  .  Broad- 
bent,  Dusaussay,  Leloir  and  others  have,  however,  presented  a  number  of 
cases  in  which  other  parts  of  the  brain  were  affected. 

A  common  form  of  hemorrhage  is  meningeal.  Goodhart  ^  has  written 
an  exhaustive  paper  upon  this  subject,  in  which  49  cases  are  given,  prov- 
ing most  conclusively  its  connection  with  diseased  kidney  and  hypertro- 
phied  heart.  Of  these  49  cases,  30  were  due  to  renal  disease,  and  six  had 
uncomplicated  heart  trouble.  When  the  hemorrhage  takes  place  above 
the  arachnoid,  we  are  assured  by  Mr.  Prescott  Hewitt  ^  that  the  blood 
very  rarely  gravitates  to  the  base  ;  but  when  the  hemorrhage  is  sub-arach- 
noid, the  blood  may  find  its  way  below,  thus  making  the  condition  a  most 
serious  one.  After  death  a  peri-cortical  collection  of  blood  will  be  found  ; 
which  is  extensive  over  the  base,  and  probably  produces  death  by  pres- 
sure upon  the  pons  and  medulla.  (See  Chronic-Pachymeningitis  with 
H^ematoma.) 

Diagnosis. — Coincident  with  the  occurrence  of  the  hemorrhage,  symp- 
toms will  be  presented  which  may  enable  us  to  localize  with  some  degree 
of  accuracy  the  position  of  the  clot,  its  extent,  and  character,  and  the  fol- 
lowing statements  are  based  upon  the  observations  of  Bastian,  Wilks,  and 
others  :  A  lesion  in  or  about  the  corpus  striatum  will  be  followed  by  hemi- 
plegia of  the  opposite  side.  The  temperature  being  higher  in  the  para- 
lyzed limbs  than  in  the  others  ;  the  eyeballs  will  deviate  towards  the  side 
of  the  lesion  ;  and  the  tongue,  when  protruded,  will  point  to  the  hemiplegia 
side.  The  face  is  paralyzed  on  the  same  side  as  the  arm  and  leg.  A  le- 
sion in  or  about  the  optic  thalamus  will  present  the  same  phenomena,  only 
that  the  temperature  is  higher  in  the  paralyzed  limb  than  in  the  preceding 
form,  A  lesion  in  one  crus  is  followed  by  very  much  the  same  symptoms. 
If  the  under  and  inner  part  be  affected,  we  find  cross  paralysis,  the  face 
being  paralyzed  on  the  side  of  the  lesion,  while  the  extremities  are  para- 
lyzed on  the  other  side  of  the  body.  Hemiansesthesia  is  quite  marked  ;  and 
the  third  and  seventh  nerves  are  paralyzed,  so  that  ptosis  and  profound 

^  Archives  de  Medicine,  Jan.  1876. 
''-  Guy's  Hosp.  Kep.,  vol.  xxi.  p.  131. 
^Holmes's  System  of  Surgery,  1870. 


116         DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

facial  paralysis  result.  A  lesion  in  one  lateral  half  of  the  pons  is  followed 
by  hemiplegia  of  the  opposite  side,  profound  coma,  deviation  of  the  eyes 
away  from  the  side  of  the  lesion,  facial  paralysis  on  the  side  of  the  lesion, 
lowered  temperature  in  the  non-paralyzed  limbs,  paralysis  of  the  muscles 
of  deglutition,  and  anaesthesia  or  hyperesthesia  of  parts  supplied  by  the 
fifth  nerve.  A  lesion  of  the  upper  half  of  the  lateral  region  of  the  pons  will 
be  expressed  by  pretty  much  all  of  the  symptoms  which  follow  the  last 
mentioned  lesion,  except  that  the  facial  paralysis  will  be  on  the  side  op- 
posite the  lesion,  A  feature  of  all  forms  of  lesions  in  the  pons  is  the  very 
decided  character  of  the  facial  paralysis ;  and  if  there  be  extension  of 
the  lesion,  there  may  be  double  facial  paralysis,  with  hemiplegia  of  the 
body.  A  lesion  in  the  posterior  j^f^rt  of  the  pons,  beside  the  symptoms  just 
alluded  to,  will  produce  paralysis  of  the  fifth,  sixth,  and  seventh  nerves  on 
the  side  of  the  lesion  ;  or,  according  to  Brown-Sequard,  it  may  sometimes 
produce  cross-paralysis.  A  lesion  in  the  centre  of  the  jwns  is  followed  by 
double  paralysis,  deep  coma,  marked  contraction  of  pupils  (while  in  the 
other  forms  one  pupil  may  be  contracted  on  the  side  of  the  lesion),  lower- 
ed temperature  on  both  sides,  with  ultimate  rise  and  but  slight  loss  of 
sensation.  Liouville^  reports  a  case  of  hemorrhage  into  the  pons,  in 
which  sugar  was  found  in  the  urine.  This  he  considers  to  be  an  ever- 
present  symptom  of  disease  in  the  lower  part  of  the  pons,  but  never  a 
feature  of  disease  of  the  upper  part.  A  hemorrhage  in  the  medulla  is 
followed  by  paralysis  of  the  cranial  nerves  on  both  sides,  bilateral  para- 
lysis of  the  body,  and,  generally,  rapid  death.  Extensive  lesions  may 
produce  a  combination  of  these  phenomena,  and  diagnosis  may  sometimes 
be  an  extremely  difficult  matter.  A  patient  under  treatment  with  sy- 
philitic disease  of  the  brain,  presents  a  combination  of  symptoms  which 
are  extremely  interesting  in  a  diagnostic  sense. 

Wm.  McG.,  aged  58  years,  when  about  21  years  of  age,  had  a  primary 
chancre  upon  the  dorsum  of  the  penis,  followed  some  months  afterwards 
by  secondary  symptoms.  After  a  few  years  all  traces  of  syphilitic  trouble 
seemed  to  have  disappeared,  as  he  enjoyed  extraordinary  good  health. 
He  has  led  for  the  last  twelve  or  fourteen  years  a  very  intemperate  life, 
and  has  regularly  "  gone  upon  sprees."  Twenty-six  months  ago,  after  an 
attack  of  facial  neuralgia,  which  was  evidently  specific,  he  became  herai- 
plegic  during  one  of  his  drinking  bouts,  but  does  not  remember  any  of  the 
circumstances  immediately  connected  with  the  apoplexy.  AV^hen  he  be- 
came sober  he  found  that  the  left  side  was  paralyzed,  but  the  loss  of 
power  could  not  have  been  very  great,  for  he  was  able  to  walk  in  a  few 
days.  About  a  year  ago  the  right  side  of  the  face  became  aniesthetic,  and 
he  began  to  lose  the  sense  of  taste  on  the  left  side ;  at  the  same  time  he 
found  it  difficult  to  arrange  the  food  for  mastication,  and  his  power  of 
articulation  became  embarrassed. 

Present  Condition. — Eyes.  Pupils  of  the  same  size,  and  not  abnor- 
mal ;  respond  well  to  light ;  no  ptosis,  nor  disturbance  of  vision  ;  no  retinal 
change.  Face. — No  impairment  of  buccal  muscles,  nor  of  superficial 
facial  muscles,  except  slight  contraction  of  those  of  right  side  when  he 

^  Gazette  des  Hopitaux,  Feb.  8,  1873. 


CEREBRAL    HEMORRHAGE. 


117 


opens  liis  mouth.  When  this  is  clone,  the  orifice  is  unsymmetrical.  Anos- 
mia marked,  taste  impaired  to  slight  degree.  Warm  substances  produce 
an  impression  on  sound  side  of  tongue,  but  not  on  the  other.  Left  side  of 
the  palate  paralyzed,  and  lower  than  the  other.  Left  side  of  tongue  atro- 
phied, presenting  the  appearance  depicted  in  Fig.  21 ;  and  when  protruded 
the  tip  points  to  the  right  side,  no  apparent  tactile  loss  of  sensation  as  de- 
termined by  the  sesthesiometex.    Saliva  is  secreted  in  large  quantities,  and 

Fiff.  21. 


Multiple  Lesion  with  Tongue  Atrophy. 

constantly  drips  from  the  angles  of  the  mouth  when  he  talks.  Sensation 
of  right  side  of  face  impaired  ;  feels  points  only  when  sej)arated  3  mm.  on 
other  side  1?  ;  some  difiiculty  of  speech,  especially  with  the  letter  r,  pro- 
nouncing "  righteous  "  "eightshus;"  the  left  leg  he  drags  slightly  when 
he  walks.  Six  months  ago  he  slept  upon  his  arm  when  drunk,  and  thereby 
added  to  his  other  troubles  a  decubitus  paralysis ;  slight  loss  of  power  in 
both  arms. 

In  this  case  there  were  evidently  two  lesions — one  in  the  medulla,  and 
the  other  on  the  right  side  of  the  brain — one  hemorrhagic,  the  other  of 
slow  growth. 

We  are  to  diagnose  the  symptoms  of  cerebral  hemorrhage  in  its  different 
stages  from  those  of  the  following  diseases :  Actual  attack  from  ursemia, 
drunkenness,  opium  poisoning,  tumor,  epilepsy,  compression  or  concussion 
from  injury,  embolism,  and  thrombosis.  There  are  certain  general  ap- 
pearances which  symptomatize  the  unemic  condition,  and  can  hardly  be 
mistaken  ;  the  skin  is  waxy  and  oedematous,  the  eyelids  are  puffed,  and 


118         DISEASES    OF    THE    CEREBRUM    AND     CEREBELLUM. 

the  legs  and  feet  swollen ;  but,  as  Bastian  suggests,  it  does  not  always 
follow,  when  Ave  find  these  appearances  in  an  individual  over  thirty 
years  of  age,  that  the  coma  is  always  purely  of  an  urismic  character,  and 
that  there  may  not  be  a  complicating  hemorrhage.  The  urine,  when 
drawn,  is  found  to  contain  albumen,  but  this  symptom  by  itself  is  in- 
sufficient to  settle  the  question.  Ursemic  coma  is  generally  of  gradual 
appearance,  though  Hughlings  Jackson  calls  attention  to  a  form  which 
has  a  rapid  onset,  with  convulsions ;  but,  on  the  whole,  such  sudden 
appearance  is  more  suggestive  of  cerebral  hemorrhage.  It  is  nearly 
always  preceded  by  prodromata  for  several  days.  The  patient  is  stupid, 
and  inclined  to  somnolence,  and  has  headache.  Bourneville  has  ascer- 
tained that  the  temperature  rapidly  sinks  when  the  coma  begins,  to  a 
point  very  much  lower  than  it  does  in  cerebi'al  hemorrhage,  and  con- 
tinues depressed  during  the  condition,  while  the  converse  is  true  in  the 
other  affection.  Convulsions  are  much  more  prominent  and  constant 
features  of  uriemic  coma  than  they  are  of  cerebral  hemorrhage ;  and,  be- 
side, there  is  no  paralysis.  Numerous  other  indications  will  serve  to 
make  the  diagnosis  clear  in  this  respect.  The  coma  is  not  dee]),  and  it  is 
possible  to  arouse  the  patient,  and  there  is  great  hyperkinesis,  there  being 
a  tendency  to  muscular  spasm  and  rigidity  which  is  not  unilateral.  The 
character  of  the  respiration  differs  from  that  of  cerebral  hemorrhage,  the 
stertor  being  more  superficial.  From  drunkenness  the  diagnosis  is  not 
always  so  easily  made,  the  two  conditions  sometimes  coexisting,  and  it 
may  be  necessary  to  delay  until  the  effect  of  the  alcohol  has  passed  away, 
before  we  can  determine  our  patient's  true  condition.  The  odor  of  liquor, 
the  circumstances  under  which  he  was  found,  and  his  imperfect  loss  of 
consciousness,  are  sufficient  to  excite  suspicion.  If  he  vomits,  we  may 
chemically  test  the  substances  thrown  up,  or  examine  the  urine. 
Anstie  gives  a  delicate  test  which  may  be  employed.  If  even  only  one 
drop  of  the  urine  of  the  patient  who  has  taken  a  toxic  dose  of  alcohol  be 
added  to  fifteen  minims  of  a  solution  of  one  part  of  bichromate  of  potash 
in  three  hundred  parts  of  strong  sulphuric  acid,  the  mixture  will  turn 
to  an  emerald  green.  With  a  larger  quantity  this  test  will  be  much  more 
certain.  The  articulation  of  an  intoxicated  person  when  aroused  is  so 
peculiar  and  so  interrupted  by  hiccough  that  there  need  be  no  chance  for 
mistake  in  this  respect.  Narcotic  poisoning  may  resemble  somQwhsxt  the 
symptoms  indicating  cerebral  hemorrhage.  Like  alcoholic  coma,  its 
advent  is  gradual,  and  there  are  convulsions,  while  the  face  is  dusky, 
but  the  patient  may  be  generally  aroused.  Much  stress  has  been  laid 
upon  the  condition  of  the  pupil  in  opium  poisoning  as  a  diagnostic  sign  ; 
but,  as  this  symptom  is  indicative  of  hemorrhage  in  the  pons,  it  loses 
some  of  its  value.  Epileptic  coma  can  hardly  be  mistaken  (should  it  be 
a  stage  of  the  actual  epileptic  attack)  for  that  of  cerebral  hemorrhage. 
In  the  former  there  is  a  history  of  convulsions  ;  the  stupor  lasts  but  for 
an  hour  or  two  at  the  most ;  the  temperature  is  elevated  ;  and  there  is 
sometimes  an  escape  of  bloody  froth  from  the  mouth.  The  previous 
history  of  the  patient  should  set  all  other  doubts  at  rest.     Compression  or 


CEKEBKAL    HEMORRHAGE.  119 

concussion  from  head  injuries  may  be  mistaken  for  the  condition  under 
consideration.  In  the  former  there  may  be  a  subarachnoid  effusion, 
which  may  give  rise  to  many  of  the  symptoms.  The  latter  is  usually 
of  short  duration, 'so  far  as  symptoms  are  concerned.  The  skin  is  pale, 
the  pupils  dilated,  and  vomiting  occurs  at  some  time  or  other.  It  is  al- 
ways of  decided  importance  that  we  should  inquire  into  the  nature  and 
receipt  of  the  injury  ;  for,  should  it  follow  a  fall  while  the  patient  is  in  a 
safe  position,  we  may  suspect  that  he  has  had  a  seizure  of  some  kind, 
the  injury  being  secondary  to  the  attack. 

The  internal  cause  of  the  hemorrhage  is  always  important,  whether  it 
be  produced  by  an  abscess,  tumor,  or  other  intracranial  disease  states  ; 
and  these  things  are  to  be  taken  into  account.  The  antecedent  history 
of  the  patient,  the  presence  of  pain  of  a  localized  character,  subsequent 
convulsion,  loss  of  vision,  aural  disease,  and  kindred  conditions  should 
all  be  ascertained.  Serous  apoplexy,  as  it  has  been  called,  when  an 
immense  effusion  of  serum  takes  place  either  beneath  the  investing 
membrane,  or  in  the  ventricles,  or  throughout  the  brain  substance, 
is  usually  of  gradual  origin;  and  dependent  uj)on  the  collection  of 
fluid  which  takes  the  place  of  atrophied  brain  substance  or  attenuated 
vessels. 

Prognosis. — According  to  all  observers  it  is  an  exceedingly  difficalt 
matter  to  make  a  prognosis  with  any  certainty,  especially  an  early  one, 
and,  consequently,  it  is  of  the  utmost  importance  that  every  circum- 
stance of  the  case  should  be  taken  into  account  and  carefully  considered 
before  we  give  expression  to  any  opinion.  Certainty  of  prediction  is 
made  doubtful,  by  new  complications,  and  fresh  dangers  that  are  likely 
to  arise.  There  are  several  questions  that  are  to  be  answered,  and  the 
first  of  these  concerns  the  fatality  of  the  actual  attack.  The  character 
of  the  coma,  its  depth  and  duration,  the  appearance  of  convulsions,  aboli- 
tion of  reflex  excitability,  stertor,  involuntary  passage  of  urine  and  feces 
are  to  be  regarded  as  indicative  of  an  early  fatal  termination.  If  this 
condition  be  connected  with  unequal  pupils,  and  double  hemiplegia,  the 
prognosis  is,  if  anything,  more  unfavorable.  Large  hemorrhages  into 
the  ventricles,  corpora  striata,  or  into  the  crura  or  pons  are  then  to  be 
feared.  The  patient  presenting  these  alarming  symptoms  dies  usually 
in  a  very  short  time,  say  in  from  a  few  hours  to  two  or  three  days,  and 
there  may  be,  perhaps,  an  aggravation  of  the  symptoms  towards  the  end 
as  the  result  of  fresh  hemorrhage.  If  he  survives  the  attack,  what  are 
the  chances  for  the  return  of  mental  power?  or,  if  not  affected,  will  it 
subsequently  become  impaired  ?  This  depends  very  much  upon  the 
occurrence  of  inflammatory  action  about  the  clot,  or  whether  there  be 
ursemic  trouble  or  softening.  We  may  augur  well  for  his  chances  if 
these  conditions  are  absent,  and  if  he  lives  for  eight  or  ten  days  after 
the  immediate  attack.  In  regard  to  the  speech  disturbances  :  if  there  be 
simple  ataxia,  there  is  no  reason  to  fear  ;  if,  however,  any  marked  for- 
getfulness  of  words  or  genuine  aphasia  exists,  the  prognosis  is  less  hope- 
ful.    This  condition  of  affairs  often  exists  for  years  without  the  slightest 


120         DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

improvement  taking  place.  At  first  the  mind  is  confused  and  dull,  and, 
unless  the  hemorrhage  is  the  result  of  softening  or  other  degeneration, 
there  is  but  little  doubt  that  he  will  ultimately  regain  his  mental  activity. 
It  is,  however,  well  to  qualify  this  statement  by  saying  that  in  old  people 
the  tendency  is  the  other  way.  Congenital  apoplexies,  or  those  occurring 
in  early  life,  are  apt  to  leave  sequelas  of  the  most  deplorable  description, 
such  as  imbecility  and  kindred  conditions.  The  return  of  muscular  power 
and  normal  sensation  is  the  most  important  question  to  be  next  con- 
sidered, for  much  of  the  patient's  future  comfort  depends  upon  the  re- 
covery of  his  lost  power.  Should  the  limbs  remain  paralyzed,  or  second- 
ary neuritis  take  place,  the  consequence  will  be  atrophy  and  contractures, 
such  as  I  have  described.  It  is,  however,  usual  for  recovery  to  begin  in 
a  few  weeks,  and  in  even  a  shorter  time  should  the  hemorrhage  be  unat- 
tended by  loss  of  consciousness.  The  limb  first  to  recover  is  the  lower 
extremity.  He  is  able  after  a  short  time  to  get  out  of  bed  and  "  hobble  " 
about,  or  he  may  retain  a  certain  degree  of  power  from  the  first  should 
the  hemorrhage  be  slight.  He  is  subsequently  able  to  raise  his  hand  to 
his  head,  and  ultimately  recovers  entirely.  But  this  improvement  does 
not  always  occur,  for  during  cerebritis,  and  secondary  degeneration 
which  may  subsequently  take  place,  a  number  of  serious  muscular  dis- 
tortions of  a  permanent  character  may  ensue.  A  case  illustrating  this  is 
the  following : — 

J.  C.  D.,  aged  53,  born  in  Ireland  ;  carman.  Family  history,  mother 
died  of  old  age  ;  father  died  of  renal  disease.  The  patient  in  early  life 
was  very  intemperate,  and  there  are  some  evidences  of  syphilitic  trouble, 
there  being  nodes,  bald  spots,  and  enlarged  glands  ;  but  he  denies  any 
venereal  disease.  For  three  months  previous  to  the  attack  (it  occurred 
three  years  ago)  he  suffered  from  headache,  dizziness,  and  other  prodro- 
mal symptoms  ;  none  very  marked,  however.  He  went  to  bed  one  night 
feeling  perfectly  well,  and  awoke  with  "  cramps,"  which  affected  his  right 
leg  ;  he  called  his  wife,  and  attempted  to  get  out  of  bed,  when  he  found 
he  was  paralyzed.  There  was  no  speech  trouble  whatever.  He  was  placed 
in  bed,  and  remained  there  for  three  months,  during  which  time  he  had 
violent  headache  in  the  occipital  region. 

Present  Condition. — Hemiplegia  of  right  side,  sensibility  slightly  im- 
paired, and  no  atrophy  of  either  the  arm  or  leg.  When  he  stands  there 
is  slight  rigidity  of  the  inner  ham-strings.  The  toes  and  the  end  of  the 
foot  are  adducted ;  and  when  he  walks,  the  foot  is  raised  from  the  ground 
about  one  inch ;  the  knee  is  rigid,  and  there  is  motion  only  at  the  hip- 
joint.  The  fingers  of  the  right  hand  are  in  a  condition  of  extreme 
flexion,  and  cannot  be  extended  by  ordinary  force  ;  but,  when  the  hand 
is  placed  in  hot  water  for  some  time,  the  rigidity  is  partially  overcome. 
The  thumb  is  not  involved ;  but,  when  the  distal  phalanx  was  extended, 
it  could  be  bent  backwards  some  distance,  and  remained  in  this  condition 
until  it  was  restored  by  me.  The  hand  is  slightly  flexed,  and  the  fore- 
arm pronated  and  flexed  on  the  arm,  and  the  arm  adducted  to  the  body. 
No  lateral  movement  is  possible.  There  was  an  early  history  of  neuritis, 
which  came  on  a  short  time  after  the  attack,  with  decided  pain  in  the 
shoulder-joint,  during  which  the  patient  applied  blisters  and  mustard 
poultices.  The  dynamometer  indicates  20,  outer  circle,  with  the  right 
hand,  and  80  with  the  left.     There  is  no  visible  facial  paralysis,  but  the 


CEREBRAL    HEMORRHAGE.  121 

tongue  points  slightly  to  the  right  side.     The  surface  of  the  paralyzed 
side  is  mottled  and  cold,  and  the  nails  are  crenated  and  horny. 

The  facial  paralysis  is  sometimes  a  grave  and  permanent  condition, 
and  is  very  serious,  especially  if  there  be  ptosis.  Should  the  paralysis 
involve  the  muscles  of  the  pharynx,  the  tongue,  or  the  buccal  muscles, 
the  prognosis  is  very  bad,  and  these  symptoms  suggest  that  the  hemor- 
rhage has  invaded  the  posterior  basal  parts  of  the  brain,  and  perhaps 
the  medulla.  The  organs  of  special  sense  are  affected  to  a  variable  ex- 
tent, and  greatly  modify  the  prognosis.  If  there  be  involvement  of  the 
optic-discs,  retinal  extravasations,  or  structural  changes  of  the  fundus,  a 
grave  character  is  given  to  the  disease ;  while  such  symptoms  as  ptosis 
and  diplopia,  which  depend  upon  paralysis  of  the  third  and  sixth  nerve, 
sometimes  disappear  after  a  time,  though  such  disappearance  may  very 
slowly  take  place.  The  recurrence  of  apoplectic  attacks  is  not  uncom- 
mon, and  if  there  be  any  special  cachexia,  they  are  to  be  dreaded.  Sy- 
philis and  gout,  as  well  as  renal  disease,  are  highly  conducive  to  a  return 
of  the  trouble ;  or  advanced  age  is  an  important  predisposing  cause  of 
cerebral  hemorrhage.  When  we  find  a  calcareous  state  of  the  arteries 
with  cerebral  hemorrhage,  it  is  very  probable  that  the  other  fluxions  will 
follow.  I  remember  a  case  in  Avhich  a  succession  of  hemorrhages  oc- 
curred in  the  person  of  a  middle-aged  lady,  the  third  of  which  proved 
fatal :  — 

N.  G.  A.,  aged  57.  On  the  evening  of  February  3,  1873,  I  was  called 
by  Dr.  Wm.  H.  Bennett  to  see  the  patient,  whom  I  found  in  a  state  of 
coma.  All  of  the  characteristic  appearances  of  a  profuse  cerebral  effu- 
sion were  manifested.  The  apoplectic  seizure  had  taken  place  the  day 
before,  and  she  had  continued  in  a  comatose  state  until  I  saw  her  with 
Dr.  Bennett.  Her  surface  was  cool,  her  breathing  slow  and  stertorous, 
her  pupils  dilated,  and  cornea  insensitive  to  the  touch  ;  while  reflex  ex- 
citability was  entirely  abolished,  so  that  tickling  of  the  soles  was  followed 
by  no  withdrawal  of  either  limb.  In  this  state  she  remained  until  the 
8th  of  the  month,  during  which  time,  and  in  fact  until  the  time  of  her 
death,  in  November  of  the  same  year,  it  was  necessary  to  draw  her  water 
nearly  every  day.  At  the  end  of  the  fifth  day  there  was  a  slight  return 
of  consciousness,  but  entire  inability  to  speak,  the  patient  making  a  pecu- 
liar short  sound  when  she  wished  to  communicate  with  those  about  her. 
There  was  complete  paralysis  of  the  right  side,  bat  a  faradic  current 
readily  produced  muscular  contractions.  From  this  period  until  Septem- 
ber 13th,  there  was  steady  improvement,  and  the  family,  as  well  as  our- 
selves, were  very  hopeful.  She  recovered  considerable  power  over  the  leg 
and  arm,  but  was  unable  to  get  out  of  bed,  although  she  was  lifted  from 
it  and  placed  in  an  easy  chair,  where  she  remained  contented  for  several 
hours  of  the  day.  She  was  now  able  to  utter  two  or  three  words,  and 
seemed  to  take  a  lively  interest  in  all  that  went  on  about  her.  On  the 
13th  of  September,  while  lying  in  bed,  she  suddenly  became  comatose, 
and  presented  all  the  symptoms  of  a  fresh  hemorrhage.  Her  tempera- 
ture, which  had  before  ranged  between  98°  and  101°,  now  sank  to  96°  ; 
and  her  condition  was  so  critical  that  I  remained  with  her  during  the 
night  of  the  14th,  when  she  slightly  recovered,  regaining  her  conscious- 
ness on  the  17th ;  but  there  was  complete  loss  of  power.  The  tempera- 
ture now  rose  to  104°,  and  she  was  restless  and  irritable.     Her  power 


122        DISEASES    OF    THE    CEREBRUM    AXD    CEREBELLUM. 

of  expression  had  entirely  disappeared,  and  she  remained  in  this  state 
until  the  l^th  of  November,  -when  she  died  in  her  last  apoplectic  attack. 

This  patient,  before  her  last  illness,  had  suffered  for  some  time  from 
albuminuria,  but  her  symptoms  had  been  almost  entirely  relieved  when 
her  first  cerebral  hemorrhage  took  place.  She  was  of  spare  build,  her 
radial  arteries  were  rigid,  and  the  arcus  senilis  was  visible  to  a  limited 
extent. 

This  tendency  to  cerebral  hemorrhage  is  sometimes  seen  in  gouty  sub- 
jects. A  patient  recently  sent  to  me  by  Dr.  William  Lockwood,  of  Nor- 
walk,  Conn.,  had  sufiered  for  years  from  gouty  trouble.  Besides  the  pain, 
her  joints  presented  gouty  swellings,  with  chalky  concretions.  Within 
the  past  five  years  she  has  suffered  from  slight  hemiplegia  of  both  sides  ; 
on  the  right  most  severely.  In  this  case  it  is  probable  that  the  rupture 
of  a  large  vessel  will  some  day  carry  her  off. 

Treatment. — Our  treatment  must  be,  first,  preventive,  second,  for 
the  attack,  and  third,  for  the  amelioration  of  the  resulting  condition.  If 
we  have  to  deal  with  cachexias  of  different  kinds,  appropriate  treatment 
is  indicated.  Should  there  be  gouty  trouble,  albuminuria,  or  syphilis, 
these  are  to  be  met  with  alkalies,  diuretics,  and  specific  remedies,  such  as 
mercury  and  the  iodides.  If  there  be  depraved  general  health,  weak 
heart  action,  and  general  debility,  we  are  to  support  our  patient  by  qui- 
nine, stimulants,  and  nourishing  food.  Cambiuations  of  digitalis  and  iron 
are  especially  useful  when  there  is  low  arterial  tension,  and  rapid  heart 
action.  In  speaking  of  cerebral  congestion  I  alluded  to  the  conditions 
which  might  favor  an  excessive  flow  of  blood  to  the  head,  and  advocated 
special  forms  of  treatment.  It  is  not  necessary  to  repeat  these  indications, 
but  I  will  simply  refer  to  the  value  of  the  bromides  given  in  doses  of  from 
20  to  30  grains  three  times  a  day  if  there  be  any  tendency  to  head  fulness, 
while  ergot  administered  in  half-drachm  doses  two  or  three  times  during 
the  24  hours,  and  the  abstraction  of  blood  from  behind  the  ears,  may  be 
resorted  to,  should  there  be  a  suspicion  of  immediate  danger.  The  patient 
is  to  be  kept  perfectly  quiet  in  a  cool  room,  cold  applications  are  to  be 
made  to  the  head,  and  his  bowels  should  be  emptied  by  some  such  cath- 
artics as  the  compound  jalap  powder,  senna,  or  Rochelle  salts.  Should 
we  recognize  the  appearance  of  any  prodromal  symptoms,  we  must  im- 
mediately inform  the  patient  of  the  dangerous  possibility,  and  enjoin  upon 
him  the  necessity  of  regulating  his  mode  of  life,  of  breaking  ofi'  bad 
habits,  and  using  every  means  in  his  power  to  improve  cutaneous  circula- 
tion. The  flesh-brush,  cold,  and  sometimes  Turkish  baths,  moderate  out- 
door exercise,  and  other  agents  which  stimulate  the  surface  capillaries  and 
relieve  internal  congestion,  should  be  as  soon  as  possible  resorted  to.  The 
patient's  diet  should  be  farinaceous,  and  the  use  of  either  strong  drink  or 
condiments  is  to  be  at  once  discontinued.  He  is  to  sleep  in  a  cool  room, 
and  on  no  account  wear  tight  neck  gear.  The  feet  are  to  be  kept  warm, 
and  thick  woollen  stockings  should  be  recommended.  Violent  exertion, 
especially  forms  requiring  any  fixation   of  the  abdominal  muscles  or 


CEREBRAL    HEMORRHAGE.  123 

straining,  are  also  to  be  carefully  guarded  against.  Should  we  be  called 
to  find  the  patient  in  the  actual  apoplectic  state,  another  line  of  treatment 
must  be  followed  out.  If  in  this  condition  he  is  found  lying  in  a  coma- 
tose state  upon  the  floor,  he  is  to  be  lifted  gently,  carried  to  a  bed,  and 
well  propped  up  by  pillows,  so  that  the  head  is  elevated.  The  room 
should  be  kept  cool  and  well  ventilated,  and  cold  applications  are  to  be 
applied  to  his  head,  while  his  feet  may  be  kept  warm  by  contact  with 
bottles  filled  with  hot  water.  The  room  is  to  be  darkened,  and  his  collar 
and  shirt  collar  band  should  be  cut  or  ripped  off,  so  that  the  flow  of  blood 
to  and  from  the  head  shall  be  unembarrassed.  It  is  essential  to  keep  him 
perfectly  quiet ;  so  loud  talking  is  to  be  forbidden,  and  officious  friends 
kept  away.  In  times  gone  by,  it  was  customary  always  to  bleed  at  this 
stage.  I  think  experience  has  clearly  proven  how  dangerous  is  such  prac- 
tice, for  hemorrhage  in  the  brain  is  very  apt  to  be  started  afresh  by  any 
such  measure.  If,  however,  the  pulse  be  full,  strong,  and  bounding,  the 
patient's  face  flushed,  and  his  condition  one  of  plethora,  the  abstraction 
of  a  few  ounces  of  blood,  from  behind  the  ears,  with  cold  douches  to  the 
head  and  mustard  plasters  to  the  calves,  will  do  much  good.  .  This  condi- 
tion may  be  so  patent  to  the  observer  that,  perhaps,  in  rare  instances,  and 
after  careful  deliberation,  he  may  decide  to  abstract  ten  or  twelve  ounces 
from  the  arm.  If  we  hear  that  he  has  been  constipated  for  several  days, 
a  drop  or  two  of  croton  oil  or  half  a  grain  of  elaterium  may  be  given  in 
a  wafer,  or  applied  to  the  tongue  if  he  is  unable  to  swallow ;  it  is  advi- 
sable to  give  the  first  remedy,  however,  if  the  jDatient  is  profoundly  coma- 
tose. Should  there  be  much  cardiac  excitement,  no  better  medicines  can 
be  recommended  than  tincture  of  veratrum  viride,  or  tincture  of  aconite; 
the  former  in  doses  of  from  6  to  8  minims  till  the  pulse  force  is  decreased, 
and  the  latter  in  rather  large  doses,  say  from  4  to  6  minims  at  a  time,  and 
after  an  interval  of  four  hours,  another  dose,  if  the  pulse  has  not  decreased 
in  volume  or  frequency.  The  medical  attendant  should  not  forget  to  draw 
the  patient's  urine  frequently.  I  have  known  a  neglect  of  this  precaution 
to  be  followed  by  pain  and  distress  which  the  patient  in  his  helplessness 
is  unable  to  express;  and  I  cannot  impress  too  strongly  upon  the  student 
the  necessity  of  remembering  this  simple  procedure.  When  consciousness 
returns  we  may  continue  the  aconite  if  it  is  indicated,  and  perhaps  com- 
bine it  with  small  doses  (say  10  grains)  of  the  bromide  of  sodium  every 
two  hours.  Active  medication  of  any  kind,  however,  is  injudicious  in  the 
extreme ;  so  it  will  not  do  to  give  large  doses.  Should  there  be  a  condi- 
tion of  prostration,  a  tablespoonful  or  two  of  milk  punch  may  be  given 
every  few  hours.  The  subsequent  management  of  the  case  is  sufficiently 
simple ;  continued  quiet,  a  moderate  quantity  of  food  easy  of  digestion, 
and  attention  to  the  functions  of  the  body  are  the  three  indications.  He 
should  not  be  allowed  to  get  up  to  defecate,  but  the  bed-pan  may  be  placed 
beneath  him.  It  may  be  found  necessary  to  give  an  enema,  which  is  bet- 
ter than  the  administration  of  purgatives  by  the  mouth,  and  in  this  case 
the  patient  should  not  be  allowed  out  of  bed,  even  though  he  may  seem 
bright  and  sufficiently  strong.     Cleanliness  should  be  insisted  upon,  and 


124        DISEASES   OF   THE   CEREBRUM    AND    CEREBELLUM. 

generally  necessitates  the  faithful  care  of  a  resj)onsible  nurse  ;  for,  if  the 
patient  is  not  carefullj'  washed,  the  iri'itatiou  produced  by  alkaline  urine 
and  his  loose  evacuations  may  favor  the  development  of  bedsores.  As  a 
precautionary  measure,  the  buttocks  should  be  rubbed  with  salt  and  whis- 
key, or,  what  is  still  lietter,  tannin  and  alcohol.  Bedsores  may  occasion- 
ally form,  and  sometimes  are  unnoticed  by  the  physician  if  he  is  not  on 
the  alert,  until  his  nose  or  the  nurse  remind  him  of  their  existence,  the 
patient  either  being  unconscious  of  such  trouble,  or  unable  to  inform  the 
physician  even  if  he  is  aware  of  their  presence.  The  patient  should  be 
immediately  put  on  a  water  bed,  and  the  slough  removed  by  poultices  of 
flax-seed  and  charcoal  which  may  be  sprinkled  with  iodoform.  At  the 
end  of  the  8th  or  9th  day,  should  the  tendency  be  to  recovery,  and  the  tem- 
perature normal,  we  are  left  with  an  ordinary  case  of  hemiplegia.  What 
is  to  be  done  next?  If  the  attack  has  been  a  serious  one  and  signalized 
by  marked  loss  of  consciousness,  and  if  the  secondaiy  rise  of  temperature 
be  high,  it  is  not  best  to  begin  electrical  treatment  for  fully  a  month  or 
longer.  If  the  muscles  respond  too  quickly  to  electric  stimulus,  we  are 
not  to  use  this  agent,  but  to  wait  for  some  days  or  weeks,  when  we  may 
cautiously  employ  the  faradic  current  to  the  muscles  of  the  affected  side. 
Large  sponge-covered  electrodes  moistened  in  a  salty  solution  should  be 
employed,  so  that  all  the  muscles  may  be  subjected  to  the  electric  stimu- 
lus in  turn.  Electrization  may  be  direct  or  indirect,  the  muscles  being 
made  to  contract  either  when  both  sponges  are  applied  to  their  bellies,  or 
when  one  is  placed  in  contact  with  the  muscle  and  the  other  is  applied 
over  the  motor  nerve  by  which  it  is  supplied.  In  certain  cases  faradiza- 
tion fails  to  do  any  good  whatever,  and  this  is  especially  the  case  when 
there  is  delay  in  the  absorption  of  the  clot  or  any  cerebritis.  Two  cases 
illustrating  the  possible  advantages  of  this  form  of  treatment  are  the  fol- 
lowing : —  , 

Right  Hemiplegia.  —  O.  S.,  aged  52,  butler,  came  under  my 
charge  October  2d,  1872.  He  had  been  deprived  of  consciousness  and 
power  of  motion  a  year  before  by  a  cerebral  hemorrhage,  and,  after  re- 
suming the  duties  of  his  avocation  some  months  afterwards,  continued 
well  till  three  months  ago,  when  a  second  attack  prostrated  him  ;  but, 
through  the  good  treatment  he  received  at  Bellevue  Hospital,  he  partially 
recovered  the  power  of  locomotion.  When  he  came  to  me  for  treatment 
there  was  complete  hemiplegia  of  the  left  side.  There  was  no  peculiarity 
in  his  gait,  beyond  a  very  slight  dragging.  The  arm  was  slightly  atro- 
phied, and  the  amount  of  power  exerted  by  a  forcible  grasp  of  the  dyna- 
mometer was  indicated  by  15°  of  the  lesser  circle.  He  could  not  button 
his  clothes,  nor  lift  his  arm  above  his  head.  There  was  no  difficulty  in 
speech,  except  it  might  be  embarrassment  in  speaking  the  words  contain- 
ing the  letters  "  b  "  and  "  p,"  when  the  labial  muscles  were  required. 

Electric  irritability  in  the  arm  was  slightly  exaggerated.  After  giving 
him  a  simple  prescription  for  his  constipation,  I  dismissed  him. 

In  three  weeks  afterward  he  returned  in  very  much  the  same  condi- 
tion. I  then  systematically  applied  the  galvanic  current  to  the  head, 
and  the  faradic  to  the  limbs.     The  improvement  was  marked  and  imme- 


CEREBRAL    HEMORRHAGE.  12§ 

diate.  The  muscles  lost  their  atrophic  state,  and  became  firmer  and 
larger.  The  patient  was  able  to  perform  many  actions  with  his  hands 
not  possible  before  this  treatment.  Faradization  to  the  lips  and  cheek 
has  effectually  overcome  the  facial  paralysis,  and  he  now  speaks  dis- 
tinctly. 

Cerebral  Softening ;  Right  Hemiplegia. — H.  Walker,  aged  62,  Germany, 
canal-boat  captain,  presented  himself  for  treatment  in  December  with  a 
well-marked  right  hemiplegia.  He  had  been  injured  some  time  before 
Avhile  on  the  deck  of  his  canal -boat,  and  then  hit  upon  the  head.  He 
was  senseless  for  some  days,  but  recovered,  with  severe  cerebral  disturb- 
ance, which,  from  his  wife's  statement,  must  have  been  inflammation  of 
the  cerebral  substance. 

He  left  his  bed  after  some  weeks,  with  persistent  pain  in  the  head, 
aphasia,  trembling,  and  a  heavy  feeling  of  the  lower  limbs.  His 
memory  and  other  mental  faculties  became  obscured,  and  there  was  an 
uneasy  expression  of  the  eyes.  About  a  year  after  the  receipt  of  his 
original  injury,  while  working  one  day  in  the  sun,  he  had  an  apo- 
plectic fit. 

After  remaining  in  bed  some  time,  muscular  power  and  cutaneous  sen- 
sibility slowly  came  back.  He  was  able  to  walk  with  difficulty;  his  speech 
was  indistinct;  the  muscles  of  both  the  leg  and  arm  were  greatly  atro- 
phied ;  and  I  determined  to  use  faradism. 

The  constant  use  of  the  veyy  mild  current  for  several  weeks  brought 
back,  to  some  degree,  the  original  contour  of  the  paralyzed  muscles.  He 
was  able  to  progress  with  a  cane,  but  his  speech  remained  imperfect. 
During  the  treatment  he  had  repeated  premonitory  signs  of  a  new  attack. 
Faradism  was  resorted  to  to  prevent  atrophy,  but  its  good  effects  were 
only  temporary,  as  there  is  still  softening. 

In  connection  with  this  treatment  we  may  give  at  the  same  time  either 
iodide  of  potassium,  strychnine,  or  ergot. 

Iodide  of  Potassium. — Should  there  be  a  syphilitic  history,  I  think  we 
may  begin  at  once  with  this  remedy.  If  there  be  no  such  dyscrasia,  I  do 
not  approve  of  the  remedy  at  any  time.  It  is  administered  very  often 
with  the  idea  of  producing  absorption  of  the  clot,  and  is  recommended  by 
many  writers.  My  limited  experience  has  convinced  me  that  its  virtues 
have  been  very  much  overestimated.  I  have  found  that  in  many  cases 
the  patient's  tendency  to  recovery  was  hastened  more  by  rest,  good  food, 
and  fresh  air,  than  by  any  other  form  of  medication.  It  is  perhaps  of 
value  in  old  cases. 

Phosphorus. — Either  in  its  pure  state,  or  in  combination  with  zinc,  it 
is  of  great  benefit  in  cases  of  long  standing,  especially  if  there  be  debility 
and  tardy  restoration  of  power  in  the  paralyzed  limb.  The  phosphide  of 
zinc  in  doses  of  one-third  of  a  grain,  or  dilute  phosphoric  acid  in  half-tea- 
spoonful  doses,  are  perhaps  better  borne  than  pure  phosphorus. 

Strychnine  is  entitled  to  more  consideration.  If  used  at  the  proper 
time,  it  is  more  powerful  to  do  good  than  any  other  remedy  I  know  of, 
perhaps  excepting  electricity.  When  the  exaggerated  electro-muscular 
irritability  subsides,  we  may  give  it  in  doses  of  1-32  of  a  grain  three  times 
a  day,  but  before  this  time  its  use  is  attended  with  danger. 


126 


DISEASES   OF   THE   CEREBRUM   AND    CEREBELLUM. 


Vance' has  recommended  hypodermic  injection  of  strychnine,  but  I 
always  hesitate  -when  injecting  an  irritating  substance  into  the  belly  of  a 
paralyzed  muscle,  for  I  have  repeatedly  seen  abscesses  follow  the  use  of 
even  a  neutral  solution  properly  injected.  Impaired  muscular  vitality  and 
tardy  reparative  nutrition  do  not  favor  its  use.  However,  Bartholow, 
Eulenberg,  and  Echeverria  recommend  its  employment,  and  have  had 
good  results.  Perhaps  in  paralysis  of  central  origin  the  trouble  to  which 
I  have  alluded  is  not  so  much  to  be  feared  as  when  the  affection  is 
peripheral.  Each  muscle  is  to  be  subjected  to  injection,  one  being  so 
treated  each  day.  Instead  of  the  plan  recommended  by  these  authorities, 
viz.,  injections  into  the  substance  of  the  muscle,  I  prefer  local  subcutaneous 
introduction  of  the  solution  by  the  hypodermic  syringe.  In  addition  to 
electric  treatment,  it  is  well  to  resort  to  massage  and  passive  movement  of 
the  contracted  members.  The  patient  may  be  directed  to  do  this  himself, 
and  he  should  be  told  to  rub  the  paralyzed  limb  several  times  daily  for  at 
least  fifteen  minutes  at  a  time.  Dr.  G.  M.  Beard  has  recommended  heat 
in  the  treatment  of  paralysis,  and  his  plan  is  to  place  the  affected  limb  in 
a  heated  earthen  drain  pipe,  well  lined  with  flannel.  I  can  quite  agree 
with  him,  but  have  found  that  alternate  heat  and  cold  applied  to  the  sur- 
face jiroduce  more  rapid  improvement  in  nutrition  of  parts  which  have  lost 
their  power.  I  originally  recommended  the  instrument  depicted  in  Fig.  22, 
which  will  be  found  a  cleanly  and  convenient  apparatus.  One  receptacle 
is  filled  with  hot  water,  the   other  with  cold.     If  the   contracted  limbs 

Fiff.  22. 


Instrument  for  .applying  Heat  and  Cold. 

where  lately  rigidity  has  taken  place  are  allowed  to  remain  daily  for 
fifteen  minutes  or  half  an  hour  in  quite  hot  water,  much  benefit  will 
follow ;  or,  should  there  be  neuritis,  we  may  use  blisters,  or  the  actual 
cautery  along  the  course  of  the  nerve  trunk.  It  is  of  the  utmost  import- 
ance that  evei'ything  should  be  done  to  improve  the  patient's  hygienic 
surroundings,  diet,  and  habits.  He  should  not  remain  in-doors,  but  stay 
in  the  open  air  as  much  as  possible.  Food  of  a  nutritious  but  not  of  a 
fatty  character,  moderate  stimulation  if  needed,  and  a  course  of  tonics, 
may  constitute  our  form  of  treatment  during  this  late  stage  of  the  dis- 
ease. 


'  Journal  of  Psychological  Medicine,  April,  1870. 


CEREBRAL   ANEMIA.  127 


CHAPTER   III. 

DISEASES  OF  THE  CEREBRUM  AND  CEREBELLUM   (Continued.) 
SYMPTOMATIC  CEREBRAL  ANEMIA. 

Synonyms. — Syncope,  Anemie  Cerebrale,  Hydrocephaloid. 

Definition. — A  morbid  state  charactei-ized  by  an  insufficient  cere- 
bral blood-supply,  and  expressed  by  impairment  of  consciousness,  pallor, 
and  much  muscular  enfeeblement.  This  disease  is  capable  of  quite  as  great 
modification  as  cerebral  hyperasmia,  as  it  may  be  what  only  appears  to  be 
a  continued  physiological  condition,  or  a  grave  pathological  state.  Cere- 
bral anaemia  may  occur  :  1,  in  an  acute  form  (syncope)  ;  2,  in  a  chronic 
form  ;  3,  in  an  infantile  form  (the  hydrocephaloid  of  Marshall  Hall)  ; 
and,  4,  it  is  localized  or  partial,  as  a  result  of  vascular  obstruction.  The 
acute  form,  which  may  be  only  a  simple  fainting  attack,  or  the  result  of 
shock  following  severe  hemorrhage,  is  the  most  familiar  variety.  It  is 
hardly  necessary  to  describe  the  alarming  and  familiar  condition  that  we 
occasionally  meet  with  after  post-partum  hemorrhage,  or  protracted  decu- 
bitus, when  the  patient  assumes  the  erect  posture.  The  chronic  variety  is 
much  less  serious  in  its  earlier  stages,  though,  when  continued,  it  is  often 
the  forerunner  of  certain  forms  of  insanity.  It  is  symptomatized  by 
lowered  function  of  the  cerebral  ganglia,  depraved  nervous  tone,  and 
general  intellectual  apathy;  for,  as  normal  circulation  is  necessary  for  the 
support  of  healthy  brain  action,  and  as  we  find  that  rapidity  of  thought 
and  emotional  activity  are  proportionate  to  the  increase  in  the  cerebral 
blood-supply,  so  must  insufficient  circulation  bring  with  it  an  impaired 
state  of  intellectual  functional  activity.  This  loss  of  healthy  action  may 
be  expressed  by  drowsiness,  obscured  intelligence,  or  by  irritability  and 
restlessness. 

The  infantile  form  generally  follows  some  of  the  continued  fevers  of 
early  life,  and  is  a  disease  of  childhood.  Occurring  during  the  stage  of 
convalescence  of  the  acute  form,  it  is  symptomatized  by  semi  consciousness, 
diarrhoea,  great  exhaustion,  insensitive  pupils,  pallor,  sighing  respiration, 
and  other  symptoms. 

The  last  variety,  local  or  partial  cerebral  ancemia,  is  that  which  is  usu- 
ally productive  of  right  hemiplegia,  and  is  due,  in  the  majority  of  cases, 
to  thrombosis  or  embolism,  and  often  has  a  grave  termination. 

It  is  hardly  necessary  to  allude  to  acute  cerebral  anaemia,  for  it  comes 
within  the  province  of  the  surgeon  rather  than  within  that  of  the  neuro- 
logist. Following  some  grave  accident  when  there  is  sudden  and  excessive 
loss  of  blood,  we  shall  find  a  corresponding  loss  of  consciousness,  and 
muscular  power,  sighing,  and  slow  respiration,  generally  vomiting,  and 
involuntary  discharge  of  feces  and  urine. 


128  DISEASES    OP    THE    CEREBRUM    AND   CEREBELLUM. 

The  condition  is  not  a  lasting  one,  and  provided  the  hemorrliage  has 
not  been  too  excessive,  nor  the  shock  too  great,  there  may  be  a  retrograde 
disappearance  of  the  symptoms,  and  ultimate  recovery. 

Symptoms. — A.  Chronic  Cerebral  An.emia.* — Pallor  of  the 
skin,  particularly  of  the  face,  which  is  of  a  dirty  white  color,  while 
the  sclerotics  are  milky  blue,  and  the  pupils  widely  dilated.  The 
patient's  expression  is  one  of  anxiety  and  depression,  and  if  the  condition 
be  advanced  and  of  long  standing,  he  will  spend  hours  with  downcast 
eyes  and  a  painful  hopelessness,  and  hebetude  stamped  upon  every  feature. 
Coldness  of  the  hands,  heart-murmurs,  and  a  weak,  small  pulse,  are  strong 
evidences  of  defective  circulation  of  this  description.  The  sphygmograph 
gives  an  almost  straight  tracing,  the  pulse-beats  being  weak  and  small. 
If  the  condition  has  gone  on  to  the  state  where  mental  impairment  has 
begun,  we  will  generally  find  that  there  is  venous  stasis,  and  that  the 
back  of  the  hands  is  of  a  livid  color,  while  pressure  leaves  a  white  mark 
which  slowly  disappears.  The  lips  are  pale,  thick,  and  puffed,  and  the 
line  between  the  mucous  membrane  and  skin  is  less  sharply  defined  than 
in  the  normal  state.  The  urine  is  passed  in  large  quantities,  is  colorless 
and  limpid,  and  of  a  low  specific  gravity.  The  heart-sounds  are  weak, 
and  it  is  not  uncommon  to  find  an  aortic  bellows  murmur.  Our  patient 
complains  of  muscular  debility,  backache,  loss  of  appetite,  and  somnolence, 
with  great  despondency,  increasing  loss  of  memory,  marked  headache,  a 
regularly  distributed  cutaneous  anaesthesia,  sometimes  nausea,  hallucina- 
tions of  sight  and  hearing,  palpitation,  indigestion,  and  constipation.  I 
have  been  told  very  often  by  these  patients  that  it  was  with  very  great 
difficulty  that  they  could  refrain  from  falling  asleep  in  public  places,  and 
one  lady  was  in  the  habit  of  becoming  so  drowsy  in  the  street  car  on  her 
way  to  my  office  that  she  very  often  unconsciously  passed  the  street.  Wo- 
men who  suffer  in  this  way  are  subject  to  fainting  attacks,  which  occur 
most  often  during  the  menstrual  period.  Among  the  most  aggravating 
symptoms  are  hallucinations  of  hearing  ;  noises — such  as  ringing  of  bells 
— are  heard  ;  and  they  occasionally  have  visual  hallucinations  in  connec- 
tion therewith.  Delusions  are  very  unusual.  Insomnia  is  sometimes  a 
distressing  symptom,  though  during  the  day,  as  I  have  before  said,  the 
patient  may  have  gi'eat  difficulty  in  keeping  awake.  It  is  not  uncommon 
for  him  to  complain  of  a  sensation  as  of  falling  through  the  bed ;  and 
one  of  the  prominent  elements  of  his  sleeplessness  is  the  continuous  roar- 
ing in  his  ears,  which  is  sometimes  compared  to  the  sounds  heard  when  a 
shell  or  other  hollow  body  is  placed  over  the  ear.  There  may  be  amauro- 
sis, and  other  defects  of  vision.  Digestive  derangements  are  quite  common, 
and  vomiting,  which  is  cerebral,  is  in  some  cases  frequent  and  obstinate. 
The  individuals  presenting  these  symptoms  are  poorly  nourished.  There 
may  be  oedema  of  the  legs   and   ankles,  and   sometimes   albuminuria. 

*  This  term  is  used  with  caution,  as  it  will  not  do  to  be  too  positive  in  making 
a  diagnosis  unless  we  .ire  sure  of  the  existence  'of  some  general  cause.  There  are  un- 
doubtedly many  cases  of  chronic  cerebral  ansemia  due  to  the  existence  of  organic 
cerebral  disease  which  present  symptoms  mistaken  very  often  for  those  of  functional 
disease. 


CEEEBEAL  ANEMIA.  129 

Feebleness  and  want  of  muscular  power,  of  a  light  grade,  are  often  ex- 
pressed ;  and  the  comfort  of  a  sofa  or  easy  chair  is  sought  by  the  patient, 
who  seems  disinclined  to  take  any  exertion  whatever. 

B.  Infantile  Ceeebeal  Anemia. — Marshall  Hall  has  called  atten- 
tion to  a  most  interesting  form  of  anaemia,  to  which  I  have  casually  refer- 
red, and  to  which  he  has  given  the  name  "  Hydrocephaloid."  The 
disease  depends  principally  upon  exudation,  and  has  its  origin  in  early 
infancy.     A  case  is  related  by  Hall :  — 

"  The  patient,  a  boy,  aged  four,  became  comatose  and  perfectly  blind 
and  deaf.  The  finger  might  approach  the  half-closed  eye  without  induc- 
ing any  movement,  but  the  moment  it  touched  the  eyelash,  the  eyelids 
would  close.  A  spoon  applied  to  the  lips  excited  their  action,  and  the 
food  it  contained  was  carried  into  the  pharynx  and  swallowed  ;  the  respi- 
ration was  frequently  suspended ;  a  sigh,  and  frequent  respiration  fol- 
lowed. The  cerebral  functions  had  ceased ;  the  true  spinal  functions  were 
made."^ 

Marshall  Hall  lays  down  certain  rules  from  which  I  may  extract  the 
following.  We  should  especially  be  upon  our  guard  not  to  mistake  the 
stupor  or  coma  into  which  the  state  of  irritability  is  apt  to  subside,  for 
natural  sleep,  and  for  an  indication  of  returning  health.  "  The  pallor  and 
coldness  of  the  cheeks,  the  half-closed  eyelid,  and  the  irregular  breathing, 
will  sufficiently  distinguish  the  two  cases."  He  divides  the  affection  into 
two  stages,  the  first  of  which  is  one  of  irritability,  the  second,  of  coma.  In 
the  former  there  is  some  attempt  at  reaction,  and  in  both  stages  there  is 
some  resemblance  to  acute  hydrocephalus. 

"  In  the  first  stage  the  infant  becomes  irritable,  restless,  and  feverish  ; 
the  face  is  flushed,  the  surface  hot,  and  the  pulse  frequent ;  there  is  an 
undue  sensitiveness  of  the  nerves  of  feeling,  and  the  little  patient  starts 
on  being  touched,  or  from  any  sudden  noise ;  there  is  sighing,  and  moan- 
ing during  sleep,  and  screaming ;  the  bowels  are  flatulent  and  loose,  and 
the  evacuations  are  mucous  and  disordered.  If  through  an  erroneous  no- 
tion of  this  afiection  nourishment  and  cordials  be  not  given,  or  if  the 
diarrhoea  continue  either  spontaneously  or  from  the  administration  of 
medicine,  the  exhaustion  which  ensues  is  very  apt  to  lead  to  a  very  difier- 
ent  train  of  symptoms.  The  countenance  becomes  pale,  the  cheeks  cool 
or  cold ;  the  eyelids  are  half  closed,  the  eyes  are  unfixed  and  unattracted 
by  any  object  placed  before  them ;  the  pupils  are  unmoved  on  the  ap- 
proach of  light ;  the  breathing,  from  being  quick,  becomes  irregular,  and 
aflEected  by  sighs ;  the  voice  becomes  husky,  and  there  is  sometimes  a 
husky  teazing  cough ;  and  evidently,  if  the  strength  of  the  little  patient 
continues  to  decline,  there  is  crepitus  or  rattling  in  the  breathing ;  the 
evacuations  are  usually  green  ;  the  feet  are  apt  to  be  cold." 

It  is  my  opinion  that  this  form  of  disease  is  very  much  more  common 
than  it  is  supposed  to  be,  and  that  many  deaths  usually  reported  as  ma- 
rasmus are  evidently  of  this  nature. 

1  Op.  cit.,  p.  181. 


130  DISEASES   OF   THE   CEREBRUM   AND   CEREBELLUM. 

Of  local  cerebral  ancemia  I  will  speak  in  another  chapter. 
Causes. — As  causes  of  cerebral  anaemia  we  may  roughly  class  all 
agents  that  interfere  with  the  cerebral  blood-supply,  and  consider  them  as 
remote  or  local.     Whether  the  fault  lies  in  a  diseased  heart,  which  is  un- 
able to  supply  the  brain  with  its  normal  amount  of  blood,  or  whether 
there  is  some  mechanical  obstruction  through  pressure  upon  the  cerebral 
arteries,  the  morbid  condition  is  the  same.    By  far  the  most  common  cause 
of  this  cerebral  condition  is  a  general  anaemia  which  may  be  dependent 
upon  a  number  of  conditions  which  drain  the  vessels.     Among  these  may 
be  enumerated  uterine  hemorrhages  of  various  kinds,  hemorrhoidal  fluxes, 
cancers  and  other  diseases  attended  by  hemorrhage,  as  well  as  general  dis- 
eases of  assimilation  which  prevent  the  proper  enrichment  of  the  blood. 
A  very  slight  reduction  in  the  quantity  of  the  blood  will  be  followed 
usually  by  indications  of  the  want  felt  by  regions  deprived  of  their  nourish- 
ment;  but  when  the  nervous  system  suffers  this  deprivation,  the  loss  is 
immediately  shown.     Haller  has  calculated  that  one-fifth  of  all  the  blood 
in  the  body  is  sent  to  the  brain,  and  with  this  fact  in  view,  it  will  not  be 
difficult  to  realize  how  any  modification  of  circulation  will  result  in  im- 
mediate changes.     Heart  disease  generally  in  the  form  of  fatty  enlarge- 
ment when  there  is  mitral  stenosis,  or  when  functional  activity  is  inter- 
fered with  by  emotional  or  other  causes,  may  have  much  to  do  with 
cerebral  anaemia.     This  cause  enters,  perhaps,  more  extensively  into  the 
production  of  chronic  cerebral  anaemia  than  any  other.     Owing  to  the 
delicate  arrangement  of  the  vaso-motor  nerves  which  so  beautifully  con- 
trol the  supply  of  cerebral  blood,  when  through  emotional  or  other  causes 
the  function  is  altered,  there  will  be  immediate  intra  as  well  as  extra- 
cranial anaemia.    We  have  all  seen  that  sudden  emotions  not  only  blanch 
the  face,  but  as  well  produce  faintness.    Various  changes  in  the  functions 
of  the  liver  may  be  associated  with  states  of  cerebral  antx^mia  through 
modification  of  function  of  this  system  of  nerves.     Milner  Fothergill  has 
pointed  out  the  association  between  the  nerves  of  this  organ  and  those 
which  supply  the  vertebral  arteries  ;  and  Schrceder  Van  der  Kolk  and  Lay- 
cock  have  held  that  those  parts  of  the  brain  suj^plied  by  the  vertebral 
arteries  were  the  seat  of  the  emotions.     Fothergill  reminds  us  of  the  fact 
that  we  may  have  functional  derangement  of  the  liver  without  affection 
of  the  intellect,  but  with  depressed  emotional  states.     There  are  other 
forms  of  abdominal  trouble,  such  as  an  overloaded  rectum  and  uterine  de- 
rangement, which  coexist  with  melancholia  and  depression  of  spirits,  and 
every  practitioner  has  seen  the  wonderful  elation  of  spirits  i^hich  follows 
a  free  movement  of  the  bowels  after  continued  torpidity  of  the  liver.    The 
extension  of  the  cerebral  vaso-motor,  and  the  involvement  of  other  areas  of 
blood-supply  may,  of  course,  make  the  condition  a  more  extensive  one, 
and  disturbances  of  motility  and  intellection  naturally  ensue. 

Pressure  made  upon  the  carotid  or  vertebral  arteries  by  various  tumors 
or  growths,  or  sometimes  by  aneurisms,  is  a  mechanical  cause  of  cerebral 
anaemia  of  decided  importance.  I  assisted  at  an  operation  several  years 
ago  where  the  carotid  on  one  side  was  tied  by  Drs.  Sands  and  Parker,  of 


CEREBRAL   ANiEMIA.  131 

this  city.  In  less  than  twenty-four  hours  the  patient  died  from  extensive 
ansemia,  owing  to  the  failure  of  compensatory  supply.  Embolism  is  per- 
haps the  simplest  example  of  a  cause  of  this  kind.  A  detached  vegetation 
or  clot  is  washed  into  the  circulation,  up  through  the  left  carotid  and  into 
the  middle  cerebral  artery  for  instance,  cutting  off  the  circulation,  and 
producing  extensive  cerebral  anaemia  on  the  left  side,  while  right  hemi- 
plegia and  aphasia  follow.  In  thrombosis  the  artery  is  narrowed  by  the 
gradual  deposit  of  plastic  substances  until  finally  its  calibre  is  occluded, 
and  the  blood  must  take  some  other  channel  or  not  reach  the  part  which 
it  normally  supplied. 

Apoplexy,  or  brain  tumors  of  various  kinds,  and  atheromatous  narrow- 
ing of  cerebral  arteries,  are  also  direct  causes.  In  the  first  two  instances 
pressure  is  made  directly  on  the  brain  substance,  and  in  the  latter  there 
is  a  gradual  change  in  the  vessels  themselves. 

As  a  familiar  illustration  of  how  cerebral  anaemia  may  be  produced  by 
a  drain  upon  the  general  vascular  system,  I  may  allude  to  the  case  of  a 
patient  whose  trouble  dated  from  a  series  of  miscarriages  occurring  within 
a  very  short  period.  One  of  these  happened  when  it  was  impossible  to 
procure  medical  attendance,  and  she  lost  a  great  quantity  of  blood. 

After  the  last  event  she  never  completely  recovered,  and  her  present 
disagreeable  and  annoying  condition  remained.  She  was  drowsy,  had 
frontal  headache,  ringing  in  the  ears ;  was  constipated,  etc.  Another  pa- 
tient was  subject  to  attacks  of  despondency,  when  life  seemed  very  dis- 
tasteful and  gloomy.  Her  appearance  was  characteristic.  White  skin, 
cold  hands,  palpitation,  and  other  symptoms  enabled  me  to  diagnose  ce- 
rebral anaemia,  and  vomiting  and  vertigo  were  confirmatory  symptoms. 
The  cause  was  found  to  arise  from  very  troublesome  hemorrhoids.  After 
cauterization  and  removal,  she  regained  her  previous  health. 

Certain  medicinal  agents,  as  well  as  tobacco,  produce  cerebral  ansemia. 
The  bromides  undoubtedly  possess  this  property,  while  chloral  and  chlo- 
,  reform,  if  taken  for  a  long  time,  as  they  often  are,  are  likely  to  provoke 
an  anaemic  state  of  the  brain  which  is  distressing  in  the  extreme.  I  can 
recall  the  case  of  a  young  lady  who  confessed  that  she  had  been  in  the 
habit  of  putting  herself  to  sleep  at  night  with  chloroform,  besides  inhaling 
it  several  times  during  the  day.  I  have  never  seen  such  a  typical  case  of 
this  morbid  condition.  Her  skin  was  of  a  hue  of  waxy  whiteness,  her 
pulse  small  and  fluttering,  her  pupils  widely  dilated,  and  her  languor 
and  muscular  feebleness  very  profound.  Depression  and  the  contempla- 
tion of  suicide  prompted  her  to  confess  her  bad  habit.  Tobacco,  though 
only  affecting  the  heart,  through  its  interference  with  pulmonary  func- 
tions, undoubtedly  produces  in  some  individuals  a  condition  of  cerebral 
anaemia.  The  clammy,  white  skin,  giddiness,  dilated  pupils,  hurried 
respiration,  and  unsteady,  weak  pulse,  and  not  uncommonly  syncope,  at- 
tendant upon  nicotine  poisoning,  are,  I  think,  evidences  of  cerebral  anae- 
mia. Certainly  the  after  effects  are  clearly  suggestive  of  this  morbid 
cerebral  condition.  That  tobacco,  in  many  individuals,  in  fact  the  great 
proportion,  possesses  stimulating  effects,  there  can  be  no  doubt ;  but  the 


132  DISEASES    OF   THE   CEREBRUM   AND    CEREBELLUM. 

variation  of  effects  which  follows  the  administration  of  opium,  for  exam- 
ple, when  there  is  some  idiosyncrasy,  clearly  leads  us  to  infer  that  its  ac- 
tion is  sometimes  different  from  that  determined  by  the  majority  of  phy- 
siologists. Physostigma,  veratrum,  aconite,  and  like  cardiac  sedatives 
may  be  mentioned  as  other  ana^miants. 

Various  conditions,  such  as  lithiasis,  are  sometimes  unsuspected,  but 
nevertheless  very  important  causes  of  cerebral  anaemia. 

Morbid  Anatomy  and  Pathology. — As  we  might  expect,  the 
ansemic  brain  is  white,  firm,  reduced  in  bulk,  and  greatly  changed.  The 
vessels  are  empty,  and  there  are  no  puncta  visible  when  a  cut  is  made 
through  the  white  matter.  We  may  find  a  distension  of  the  perivascular 
spaces,  the  ventricles,  and  arachnoid  spaces  by  fluids,  and  occasionally 
some  thickening  of  the  neuroglia. 

I  have  spoken  in  another  chapter  of  the  circumstances  which  modify 
the  cerebral  circulation.  It  only  remains  for  me  to  refer  to  the  experi- 
ments of  Kussmaul  and  Tenner,  Burrowes,  and  others,  who  have  devoted 
a  great  deal  of  attention  to  the  experimental  study  of  this  subject.  The 
experiments  of  the  first  two  observers  were  made  upon  six  adults  and  a 
number  of  rabbits.  When  the  carotids  of  the  human  subject  were 
compressed,  pallor,  loss  of  consciousness,  slow  respiration,  and  dilated 
pupils  were  produced,  which  disappeared  when  the  pressure  was  remitted, 
and  could  again  be  produced  at  will.  Tying  of  the  carotids  was  followed 
by  convulsions,  unconsciousness,  and  death,  when  post-mortem  examina- 
tion revealed  evidences  of  softening. 

In  the  first  experiments,  when  pressure  was  remitted,  there  were  evi- 
dences of  a  secondary  cerebral  hypersemia  with  flushing  of  the  face.  Ob- 
struction of  the  artery  on  one  side  may  produce  loss  of  motor  power  on 
the  other,  with  immediate  giddiness,  loss  of  consciousness,  syncope,  and 
occasionally  vomiting.  There  may  be  complete  recovery  after  such  an 
accident,  but  "  it  is  always  imperfect  when  the  obstruction  is  situated  on 
the  further  side  (from  the  heart)  of  the  circle  of  Willis."^  The  obstruc- 
tion of  the  minor  cerebral  arteries,  is  followed  by  less  complete  intellec- 
tual derangement,  by  more  marked  vomiting  and  giddiness.  Should  the 
anaemia  be  quickly  produced,  as  it  is  when  severe  injuries  have  been  re- 
ceived and  the  patient  literally  "  bleeds  to  death,"  convulsions  form  a 
prominent  and  almost  constant  symptom.  Sighing  respiration,  and  the 
other  phenomena  I  have  already  named,  are  also  expressed. 

In  cerebral  anaemia  there  is  impairment  of  functional  activity,  while  in 
congestion  the  reverse  is  the  rule.  Post-ynortem  examination  shows  that 
the  brain  in  cerebral  anaemia  is  white,  condensed,  and  less  bulky,  and  the 
vessels  are  empty. 

We  have  already  cited  the  causes  of  cerebral  anaemia,  and  it  now  re- 
mains for  us  to  consider  the  part  they  play.  Cerebral  anaemia  depends 
upon — 

^  H.  Jones,  Functional  Nervous  Disorders,  p.  66. 


CEREBRAL    ANEMIA.  133 

1.  The  insufficiency  of  cerebral  blood-supply,  through  actual  defi- 
ciency. 

2.  The  action  of  certain  agents  upon  the  nerve-filaments  themselves. 
It  is  hardly  necessary  to  again  more  than  allude  to  the  first  of  these. 

In  this  condition  the  effect  of  posture  is  said  to  greatly  influence  the  cere- 
bral state.  The  erect  position  is  conducive  to  an  aggravation  of  the 
symptoms,  while  recumbency  favors  the  flow  of  blood  to  the  brain.  This 
relief  follows  the  supine  position  when  the  individual  has  an  ordinary 
attack  of  syncope.  Abercrombie  relates  a  case  which  is  quoted  by  Foth- 
ergill,  and  which  is,  I  think,  a  beautiful  practical  example  of  this  change. 
The  patient,  who  was  greatly  reduced  by  some  gastric  disease,  gradually 
became  deaf,  but  heard  perfectly  well  when  he  lay  down  or  stooped  for- 
ward. As  soon  as  his  face  became  flushed,  the  improvement  in  hearing 
began,  and  when  he  raised  his  head  the  blush  faded  away,  and  he  relapsed 
into  his  old  condition.  Abdominal  paracentesis  is  followed  by  syncope, 
if  the  patient  is  not  made  to  assume  the  supine  position,  for  during  ascites 
the  abdominal  veins  are  so  impinged  upon  that  when  pressure  is  remitted 
they  are  capable  of  suddenly  receiving  a  very  large  quantity  of  blood — 
in  fact,  so  much  as  to  deprive  the  brain,  and  produce  anaemia.  A  quan- 
tity of  blood  gravitates  directly  through  the  superior  and  inferior  venge 
cavse,  not  being  thrown  over  by  the  right  ventricle,  but  passing  down 
into  the  abdominal  vessels. 

Insufficiency  of  cerebral  blood  may  be  due  to  a  powerless  heart,  or 
aortic  insufficiency,  that  organ  being  unable  to  lift  a  requisite  amount  of 
blood  for  the  nutrition  of  the  brain.  Not  only  may  this  be  a  direct  re- 
sult of  a  weakened  organ,  but  it  may  follow  strong  emotional  excitement. 

This  assumption  of  the  recumbent  posture  is  one  of  the  best  therapeu- 
tical means  in  certain  cases.  Dr.  Weir  Mitchell  has  had  extraordinary 
success  in  the  management  of  certain  intractable  cases,  some  of  which 
were  directly  dependent  upon  cerebral  anaemia. 

Of  the  second  mode  of  production,  I  may  allude  to  the  local  efiect  of 
some  blood  poisons,  and  the  influence  of  the  emotions.  Bearing  in  mind 
the  important  physiological  law  that  section  of  the  sympathetic  is  followed 
by  vascular  dilatation,  and  that  irritation  of  the  proximal  end  produces 
contraction,  we  are  enabled  to  realize  many  of  the  pathological  processes 
which  occur  in  the  production  of  cerebral  ansemia.  Anteriorly  the  vaso- 
motor fibres  are  derived  from  the  superior  cervical  ganglion,  and  poste- 
riorly the  fibres  come  from  the  inferior  cervical  ganglion.  These  fila- 
ments follow  the  course  of  the  large  cerebral  vessels,  and  in  this  manner 
supply  every  part  of  the  cerebral  mass. 

This  close  relation  with  the  vascular  system  explains  the  prompt  action 
upon  the  heart  of  certain  exciting  emotions,  and  secondarily  the  varia- 
tion in  blood-supply.  This  is  the  idea  held  by  Fothergill  and  others,  and 
most  admirably  explained  by  that  writer  in  an  article  in  the  West  Riding 
Reports} 

^  Art.  Cereb.  Ansemia,  vol.  iv.,  p.  108. 


134:       DISEASES   OF    THE    CEREBRUM    AND   CEREBELLUM. 

The  connection  between  variation  in  cell  action  and  the  function  of  the 
sympathetic  fibres  is,  perhaps,  the  most  interesting  part  of  the  sub- 
ject. Primarily  the  influence  of  impoverished  blood  affects  the  integ- 
rity of  the  cerebral  nerve-cells,  and  secondarily  the  influence  of  the  cere- 
bro-sjiinal  fibres  is  suspended.  I  have  no  doubt  that  a  certain  train  of 
symptoms,  which  is  sometimes  expressed  during  general  amemia,  is  the 
result  of  a  temporary  local  hypera^raia,  through  paresis  of  thevaso  motor 
fibres  ;  and  that  parts  of  the  brain  are  congested  while  others  are  anajmic, 

A  result  of  continued  emptiness  of  the  vessels  is  an  oedematous  condi- 
tion of  the  brain,  from  distension  of  the  perivascular  spaces  by  the  cere- 
bro-spinal  fluid.  This  condition  is  sometimes  so  ext-^nsive  as  to  receive 
the  name  "serous  apoplexy,"  and  profound  stupor  is  the  result. 

In  relation  to  sleep  and  its  connection  with  cerebral  antemia,  it  will 
bewell  to  say  a  few  words.  A  great  many  observers,  among  whom 
■were  Durham  and  Fleming,  strongly  held  that  the  brain  is  ani3emic 
during  repose,  the  anremia  being  the  cause  of  sleep.  Others  have 
diflPered  with  them ;  and  experimental  facts  seem  to  favor  this  view 
of  the  case.  Not  only  may  ansjemia  be  unattended  by  sleep,  but  a  condi- 
tion of  unconsciousness  closely  resembling  healthy  sleep  may  be  the  re- 
sult of  a  hypersemic  cerebral  state.  Opium,  alcohol,  and  various  agents 
■which  increase  the  cerebral  blood-supply,  act  in  this  way  ;  but  the  stupor 
■which  foilo-ws  a  toxic  dose  of  either  agent  must  not  be  confounded  with 
natural  sleep.  Certain  curious  facts  militate  strongly  against  the  anemic 
idea,  or,  at  least,  against  the  assertion  that  sleep  is  directly  dependent  upon 
a  diminution  in  the  supply  of  blood  to  the  brain. 

1.  There  are  many  anaemic  individuals  who  sleep  only  after  taking 
stimulants.  I  think  all  who  have  seen  the  good  effects  of  a  bottle  of  ale 
at  bedtime  will  be  disposed  to  take  this  view.  The  sleep  produced  in  no 
■way  resembles  stupor,  and  there  is  no  disagreeable  sense  of  fatigue  in  the 
morning. 

2.  Dr.  Janeway  made  an  interesting  experiment.  This  consisted  in  the 
administration  of  a  few  drops  of  nitrite  of  amyl  to  a  sleeping  person. 
Although  cerebral  congestion  followed,  the  patient  did  not  awake. 

3.  If  mental  action  is  dependent  upon  activity  of  the  cerebral  circula- 
tion, and  sleep  upon  anosmia,  it  almost  seems  that  dreams  must  be  incon- 
sistent with  sleep  ;  while,  on  the  contrary,  many  individuals  enjoy  the 
most  vivid  and  constant  dreams,  and  do  not  awake  till  their  usual  hour. 

I  am  more  inclined  to  think  that  the  production  of  sleep  depends  upon 
some  change  in  the  function  of  the  nerve-cell,  and  that  this  modified  form 
of  action  is  not  necessarily  dependent  upon  either  anaemia  or  congestion 
in  any  particular  case,  but  that,  if  there  be  ancemia,  it  is  secondary  to  the 
cell-change,  whatever  that  may  be. 

The  connection  of  a  torpid  condition  of  the  liver  with  cerebral  antemia 
■will  exjilain  the  constipation,  which  is  anything  but  an  uncommon  accom- 
paniment of  the  disease.  Intestinal  accumulation,  as  Fothergill  says, 
may  "  stand  to  cerebral  anremia  in  a  causal  as  well  as  a  consequential  re- 
lationship," and  he  alludes  to  the  experiments  of  Ludwig  and  Daziel  to 


CEREBRAL   ANEMIA.  135 

illustrate  tbe  connection.     A  finger  passed  over  the  intestines  produced 
acceleration  of  the  intracranial  circulation. 

The  general  symptoms,  such  as  languor,  the  various  modifications  of 
sensation,  etc.,  are  directly  due  to  a  diminution  in  nervous  supply. 

Diagnosis. — Acute  general  attacks  of  cerebral  anaemia  may  be  con- 
founded with  cerebral  congestion,  stomachic  and  auditory  vertigo.  I  have 
already  spoken  of  the  distinction  to  be  made  between  the  disease  under 
discussion  and  cerebral  hypersemia,  and  it  is  not  necessary  to  say  more. 
Attacks  of  stomachic  vertigo,  or  Meniere's  disease,  are  symptomatized 
as  follows :  The  first  is  characterized  by  a  feeling  of  "  emptiness  of  the 
head,"  reeling  and  swimming,  general  coldness ;  "  objects  whirl  around  ;" 
710  loss  of  consciousness,  nor  marked  disposition  to  sleep.  No  dependence 
upon  a  very  full  or  empty  stomach,  and  the  possible  existence  of  gastral- 
gia.  In  Meniere's  disease  there  is  aural  disease,  and  turning  or  whirling 
generally  to  one  side,  from  left  to  right,  and  the  condition  is  not  continu- 
ous. The  most  important  facts  to  discover  are  in  relation  to  the  cause, 
whether  it  be  a  secondary  condition,  the  result  of  cardiac  trouble,  or 
whether  it  be  simply  a  result  of  general  anaemia,  without  any  organic  disease. 

Chronic  cerebral  ansemia  presents  various  phases,  and  it  is  almost  im- 
possible to  go  over  the  long  list  of  general  diseases  which  it  may  be  a 
feature  of,  or,  which,  like  hysteria,  it  m^y  counterfeit.  Cerebral  tumor 
may  give  rise  to  symptoms  which  are  really  due  to  cerebral  anaemia.  So 
perfect  is  the  resemblance  that  Dr.  Hughlings  Jackson  told  me  recently 
that  it  would  be  impossible  for  him  to  make  a  diagnosis  in  many  cases 
with  any  degree  of  certainty. 

Prognosis. — As  cerebral  anaemia  is  nearly  always  due  to  some  cause 
which  is  easy  of  removal,  the  prognosis  is  good.  If,  however,  there  be 
organic  heart  trouble,  the  case  assumes  a  difierent  aspect-  Old  cases  are 
extremely  discouraging,  particularly  when  the  patients  happen  to  be 
women.  Irritability  and  hysteria  generally  enter  largely  into  the  com- 
plaint, and  treatment  is  sometimes  almost  useless.  If  uterine,  hemor- 
rhoidal fluxes,  and  other  such  drains,  exist,  of  course  their  amelioration  is 
attended  by  cure.  Should  the  loss  of  blood  be  caused  by  a  cancerous 
uterus  or  rectum,  the  prognosis  is  consequently  very  bad. 

Treatment. — It  is  of  the  utmost  importance  that  the  practitioner 
should  seek  out  and  remove,  if  possible,  such  conditions  as  diminish  the 
amount  of  blood  in  the  body,  and  consequently  he  must  ascertain  the 
existence  of  hemorrhoids,  uterine  hemorrhages,  either  periodical  or  irre- 
gular, and  apply  appropriate  remedies  in  such  cases.  Without  ventur- 
ing upon  another  field,  I  would  call  attention  to  the  necessity,  in  cases 
where  there  is  menorrhagia,  of  overcoming  this  condition  as  promptly  as 
possible,  for  special  treatment  of  the  nervous  condition  is  of  little  avail 
when  the  woman  every  month  loses  a  quantity  of  blood  largely  in  excess 
of  what  is  made  in  the  interim. 

I  have,  of  late,  had  encouraging  success  in  the  treatment  of  cerebral 
anaemia  by  means  of  nitrous  oxide  gas. 

This  gas  is  essentially   a  nervous  stimulant,  and  while  its  action   is 


136        DISEASES    OF  THE   CEREBRUM  AND   CEREBELLUM. 

somewhat  like  that  of  oxygen,  it  has  the  advantage  of  influencing  the  in- 
tellectual and  emotional  functions. 

The  use,  say  of  two  gallons  of  gas  mixed  with  one  of  air,  will  produce 
pulse  quickening  after  two  or  three  full  inhalations,  and  such  quickening 
will  be  attended  by  very  slight  flushing  of  the  face,  and  throbbing  of  the 
temporal  vessels. 

If  the  administration  be  carried  sufficiently  far  a  condition  of  tempo- 
rary unconsciousness  results,  which  is  attended  by  ansesthesia,  and  upon 
recovery,  there  is  a  certain  amount  of  reaction.  It  is  unnecessary  to  say 
that  the  extension  of  the  eflects  of  the  gas  to  this  stage  is  entirely  out  of 
the  question,  and  an  extremely  injudicious  measure  when  the  desire  is  to 
improve  circulation  and  nutrition. 

Exhilaration  of  spirits  is  the  rule  after  its  use,  not  however,  necessarily 
amounting  to  the  abandon  that  so  often  follows  the  lecture  room  experi- 
ments of  ten  or  fifteen  years  ago,  but  sufficient  to  indicate  a  very  decided 
activity  of  ideation  and  the  emotions.  Melancholic  and  taciturn  sub- 
jects became  animated  and  cheerful  in  their  address  and  behavior.  One 
of  the  patients,  of  the  late  Dr.  J.  Ellis  Blake  who  first  used  the  gas  in 
America  as  a  therapeutical  agent  in  nervous  disease,  declared  that  the 
figures  upon  his  ledger  bore  an  entirely  different  import  after  he  had 
taken  his  dose  of  gas,  and  walked  to  his  office,  and  the  debit  side  looked 
wonderfully  less  depressing.  In  another  case,  the  patient  who  had  left 
home  quite  reluctantly,  and  desired  at  first  to  go  back  immediately,  forgot 
all  his  worriments  after  the  first  two  or  three  days  of  treatment.  It  is  cer- 
tain that  in  hypochondriacal  patients  many  minor  aches  and  pains  are 
forgotten,  and  a  general  couleur  de  rose  tinges  everything. 

My  attention  was  forcibly  drawn  to  this  effect  upon  certain  patients 
after  I  had  used  it  with  melancholies,  both  in  my  private  practice  and  at 
the  Insane  Asylum  at  Blackwell's  Island.  One  of  these  had  suffered  for 
several  weeks  from  the  most  profound  despondency.  Her  trouble  had 
grown  out  of  menstrual  irregularity,  and  was  evinced  by  religious  delu- 
sions of  a  mild  type,  inclination  to  avoid  the  society  of  her  friends,  and 
an  occasional  refusal  to  eat.  The  use  of  the  gas  for  several  weeks  en- 
tirely removed  her  mental  trouble,  and  she  became  quite  cheerful.  In 
the  presence  of  Drs.  MacDonald,  Pitkin,  and  Lesynsky,  nitrous  oxide 
was  given  to  two  melancholic  patients  at  the  Female  Insane  Asylum  who 
had  refused  food,  and  had  not  eaten  voluntarily  for  two  weeks. 
Both  of  the  women  went  to  the  table  and  ate  heartily  the  same  even- 
ing- 

In  other  cases  of  melancholia  with  defective  surface  circulation,  the 
venous  stasis  which  gave  the  hand  a  dusky  purple  color  disappeared  in 
a  few  days  to  a  great  extent,  and  the  white  mark  which  remained  after 
pressure  of  the  finger  upon  the  back  of  the  hand  had  been  remitted,  did 
not  last  nearly  so  long,  nor  was  it  so  sharply  defined  as  under  other 
circumstances.  The  warmth  of  the  extremities  was  decidedly  in- 
creased, and  the  expression  of  the  eyes  was  brighter,  and  much  more  in- 
telligent. 


CEREBRAL  ANEMIA.  137 

Mitchell  ^reports  seven  cases  of  melancholia,  mania  and  dementia 
treated  with  nitrous  oxide,  in  all  of  whom  interesting  effects  were  wit- 
nessed. The  gas  was  not  administered  however,  for  its  stimulant  effects 
alone,  but  given  until  the  point  of  partial  unconsciousness  was  reached. 

Active  measures  are  necessary  when  there  is  general  ansemia,  and  for 
this  purpose  we  must  resort  to  iron,  strychnia,  phosphorus  in  some  of  its 
forms,  cod-liver  oil,  an  abundance  of  nutritious  food,  with  stimulants  such 
as  milk  punches,  porter,  or  ale. 

A  word  or  two  is  necessary  in  regard  to  the  diet,  and  the  quantity  of 
alcohol  given  to  these  patients.  It  is  the  physician's  bad  fortune  to  meet 
with  cases  of  this  kind  in  which  digestive  troubles  are  dependent  entirely 
upon  an  enfeebled  state  of  the  viscera,  and  we  should  therefore  use  great 
care  and  not  be  impatient.  A  hearty  regimen,  and  too  much  alcohol, 
may  do  mischief  instead  of  good.  It  is  well,  therefore,  in  certain  cases, 
to  give  the  stomach  as  little  work  as  possible,  and  at  the  same  time  to 
allow  it  to  exert  itself  in  a  way  that  will  most  benefit  its  possessor.  A 
very  little  food,  given  at  short  intervals,  will  be  more  perfectly  digested 
and  assimilated  than  a  large  quantity  taken  at  long  intervals.  I  have 
often  given  a  few  table-spoonfuls  of  cream  or  beef-juice  every  hour  for 
days,  and  have  ultimately  seen  such  a  marked  improvement  and  an  in- 
creased capacity  for  work  upon  the  part  of  the  digestive  organs,  that  the 
more  gross  varieties  of  animal  food,  as  well  as  alcohol,  were  after  a  while 
borne  in  large  quantities.  Should  this  enfeeblement  of  the  digestive 
organs  exist,  we  may  give  either  pancreatine  emulsion,  or  strychnia  and 
muriatic  acid.  Extract  of  malt  is  sometimes  very  well  borne,  and  hastens 
the  improvement.     This  may  be  given  in  combination  with  codliver  oil. 

One  of  the  most  useful  forms  of  treatment  to  which  I  have  already 
alluded — the  "  rest  treatment "  of  Weir  Mitchell — is  of  marked  service 
in  old  cases,  especially  if  the  subjects  happen  to  be  women.  Dr.  Mit- 
chell has  treated  many  cases  which  are  almost  identical  with  those  that 
generally  come  under  the  head  of  chronic  cerebral  ansemia.  He  says : 
"  These  cases  vary,  of  course,  endlessly  ;  but  their  essence  is  a  state  of 
reduced  nutrition,  which  no  mere  tonic  will  cure,  while  they  are  afoot 
and  living  on  their  capital.  The  main  symptoms  are  the  state  of  painful 
tire,  the  low  temperature,  the  great  or  less  ansemia,  the  quick  pulse,  the 
excess  of  white  blood."  He  calls  attention  to  the  necessity  for  perfect 
quiet,  and  at  the  same  time  daily  massage  and  faradization  of  all  the 
muscles.  His  treatment  is  expressed  in  his  own  words  thus  :  "  The 
amount  of  feeding,  of  massage,  and  of  faradic-muscle  exercise  which  each 
case  will  bear  and  prosper  under,  is  a  matter  to  be  told  early  in  the  case 
by  watching  the  pulse,  the  temperature,  and  the  appetite.  In  these  cases 
the  pulse  is  always  rapid.  If  it  fall,  if  the  temperature  rise,  above  all, 
if  there  be  the  least  gain  in  flesh,  I  know  that  I  am  on  the  right  path 
and  am  not  moving  on  it  too  fast ;  but  if  these  symptoms  be  reversed,  and 
if  the  patient  ceases  to  be  hopeful  and  looks  weary,  then  I  lessen  the  pas- 
sive exercise,   and  wait  a  little ;  but,   above  all,  I  listen   to  what  my 

1 W.  E.  Eeports. 


138         DISEASES   OF    THE    CEREBRUM   AND    CEREBELLUM. 

masseur  or  masseuse  tells  me  of  the  ease  with  which  the  limbs  flush  or 
the  readiness  with  which  the  muscles  grow  firm  under  the  kneading 
fingers,  for  in  this  matter  I  get  to  have  a  very  shrewd  judgment.  As  to 
the  rectal  feeding,  which  I  rarely  omit,  I  say  little,  as  it  is  well  under- 
stood. It  should  always  include  cod-liver  oil.  There  is  only  this  to  be 
borne  in  mind :  most  medical  men  feed  by  the  bowel  when  they  cannot 
by  the  mouth.     I  like  to  use  both  ends  at  once." 

This  treatment  seems  to  be  the  very  best  in  cases  of  long  stand- 
ing ;  but  it  is  well  to  see  first  what  fresh  air,  tonics,  and  abundant 
nitrogenous  food  will  do  for  our  patient,  while  she  pursues  her  ordinary 
life. 

The  selection  of  a  climate  for  the  nervous  patient  is  a  matter  of  great 
importance.  Dr.  Deuison,  of  Denver,  who  has  written  much  upon  this 
subject,  and  who  has  lived  in  Colorado,  speaks  with  some  caution  regard- 
ing the  benefits  of  high  altitude.  He  says :  "  The  more  acute  or  severe 
the  nervous  symptoms,  the  more  of  an  aggravating  nature  is  the  effect  of 
an  elevation." '  He  does  not  recommend  Colorado  for  patients  who  suffer 
from  epilepsy  or  cholera,  but  only  in  such  cases  where  the  diseases  of  the 
nervous  system  depends  upon  certain  dyscrasia.  Organic  diseases  are 
aggravated.  In  cases  of  nervous  exhaustion  with  anaemia  and  depres- 
sion, there  can  be  no  doubt  of  the  advantage  of  the  stimulating  climate 
of  Colorado,  and  to  such  a  place  we  might  send  our  patients,  expecting 
great  benefit. 

STOMACHIC  VERTIGO. 

Synonyms. — Vertigo  a  stomacho  Iseso  (Lat.) ;  Vertige  stomacal 
(Fr.)  ;  Gastric  vertigo. 

Definition. — A  condition  of  giddiness,  hallucination,  nausea,  head- 
ache, etc.,  without  loss  of  consciousness,  and  probably  dependent  upon  a 
reflex  excitation  of  the  cerebral  vessels  from  some  visceral  irritation. 

Symptoms. — The  condition,  which  is  a  very  common  one,  is  pro- 
duced, in  most  cases,  directly  after  a  hearty  meal,  or  else  when  the  stomach 
is  entirely  empty.  A  sense  of  gastric  fulness  at  first,  while  headache, 
with  buzzing  in  the  ears,  palpitation,  and  giddiness  of  a  few  moments' 
duration,  follow.  Should  there  be  hallucinations,  the  patient  is  not  wor- 
ried by  them,  but  realizes  their  unsubstantial  character.  Trousseau^  in- 
sists upon  the  fact  that  the  hallucinations  of  this  condition  differ  from 
those  attendant  upon  cerebral  hyperajmia  from  the  fact  that  in  this  form 
they  do  not  occur  when  the  head  is  loioered,  which  is  the  case  in  cerebral 
hypersemia. 

Causation. — Stomachic  vertigo  is  more  a  condition  of  middle  life  and 
old  age  than  one  of  youth.  Young  women  occasionally  suffer,  but  this 
is  the  exception.     Certain  forms  of  indigestible  food  may  directly  pro- 

^  Rocky  Mountain  Health  Eesorts,  p.  14-5. 
'  Clinical  Medicine,  Am.  edition,  vol.  ii.  p.  358, 


AUDITORY   VERTIGO.  139 

voke  the  attack,  or  it  may  follow  violent  exercise  after  a  hastily  eaten 
meal.  In  one  case  of  which  I  know,  a  gentleman  ran  for  over  a  mile  to 
catch  a  morning  train.  He  had  arisen  but  a  few  moments  before,  and 
had  hurriedly  eaten  his  breakfast.  He  fell  to  the  ground,  but  did  not 
lose  consciousness.  The  disorder  often  occurs  when  the  individual  has 
been  eating  irregularly  ;  and  business  men  or  others  who  take  but  little 
exercise  and  eat  hurriedly  are  very  often  the  sufferers.  Handfield  Jones^ 
considers  taenia  to  be  a  frequent  cause  of  vertigo,  and  such  has  been  my 
own  experience. 

Treatment. — Trousseau,  who  has  written  most  fully  upon  the  sub- 
ject, recommends  that  the  patient  be  directed  to  drink  every  morning  a 
glassful  of  quassia  infusion  made  by  maceration  of  the  shavings  in  water, 
or  to  use  the  goblet  of  quassia  wood  in  which  the  water  is  allowed  to  re- 
main until  it  has  become  bitter.  After  each  meal  one  of  these  powders 
should  be  taken : — 

R.  Sodse  bicarb., 

Magnesise  ealc,  aa  gr.  xv. 
Cretse  prsep.  Jss- — M. 
Divid.  in  chart,  no.  iij. — Sig.     One  after  each  meal. 

Strychnia,  pepsine,  and  sometimes  bismuth  are  excellent  remedies,  and 
should  be  given,  while  attention  is  to  be  paid  to  the  patient's  general 
habits. 

AUDITORY  VERTIGO. 

Synonyms. — Labyrinthine  vertigo  ;  Meniere's  disease. 

Definition. — A  morbid  cerebral  condition  expressed  by  vertigo  and 
rotatory  movements,  unattended  by  loss  of  consciousness,  and  dependent 
upon  disease  of  the  labyrinth,  or  other  parts  of  the  central  auditory  appa- 
ratus 

To  Meniere^  belongs  the  credit  of  having  first  accurately  described  this 
disease,  though  Triquet^  gives  the  credit  of  its  discovery  to  Saissy,  of 
Lyons,  who  observed  a  nervous  condition  connected  with  diseases  of  the 
inner  ear.  Trousseau*  says  that  Saissy  did  not  mention  vertigo  as  a 
symptom  of  the  condition  to  which  he  called  attention.  It  is  enough  to 
say  that,  prior  to  1861,  the  form  then  known  only  as  stomachic  vertigo 
was  always  supposed  to  arise  from  digestive  troubles,  and  the  existence  of 
a  distinct  variety,  with  aural  disease,  was  not  appreciated. 

Symptoms. — Generally  there  are  some  indications  of  otitis,  whether 
they  be  simple  inflammation  denoted  by  pain,  or  a  discharge  of  bloody 
pus,  or  even  perforation  of  the  tympanum.     In  many  cases  the  disease 

^  Functional  Nervous  Disorders,  p.  444. 

2  Bulletin  de  I'Academie  de  Mfed.,  xxvi.  p.  241. 

^  Lefons  cliniques  sur  les  Maladies  de  I'Oreiile,  p.  113,  Paris,  1863. 

*  Loc.  cit.,  p.  363. 


140         DISEASES    OF   THE   CEREBRUM   AND   CEREBELLUM. 

may  be  preceded  by  a  chill,  and  this  should  be  always  looked  upon  as  a 
serious  indication.  The  patient  is  suddenly  seized  with  vertigo,  and  at 
the  same  time  experiences  a  feeling  of  nausea  and  buzzing  in  the  ears, 
which  may  be  double,  or  confined  to  one  side.  This  vertiginous  condi- 
tion calls  to  mind  a  sensation  experienced  when  one  is  twirled  in  a  swing. 
A  boyish  prank  is  to  twist  the  ropes  of  a  swing  while  the  unhappy  victim 
is  seated  therein  ;  then  to  suddenly  release  the  board,  which  revolves  with 
great  rapidity  as  the  ropes  unwind.  This  description  of  the  symptom  was 
given  me  by  a  patient  who  sufiered  from  nausea  at  the  same  time  with 
vertigo.  The  vertigo  is  attended  by  a  loss  of  equilibrium.  The  patient 
sways  or  reels,  and  there  is  an  impulse  to  turn  from  the  left  to  right  when 
the  left  ear  is  affected,  and  vice  versa  when  the  other  is  the  seat  of  the  dis- 
ease. Ferrier^  describes  a  sensation  usually  experienced.  He  (the  pa- 
tient) feels  "  as  if  he  were  suddenly  lifted  from  the  ground  and  pitched 
forward  and  to  the  right  side."  There  is  also  a  tendency,  when  walking, 
to  keep  close  to  the  side  of  the  wall  or  house  which  corresponds  to  the 
affected  ear.  Deafness  is  generally  present,  but  this  is,  of  course,  the 
result  of  the  destructive  aural  disease.*  Recovery  is  not  ahvays  to  be  ex- 
pected, but  a  great  many  cases  improve  under  appropriate  treatment  pre- 
sently to  be  described. 

John  B.,  aged  47,  iron  railing  manufacturer.  Nearly  eighteen  months 
ago,  he  became  troubled  by  noises  in  the  left  ear,  which  he  compared  to 
the  "  singing  of  canary  birds,"  and  afterwards  this  subjective  noise 
changed  its  character,  and  he  described  it  as  a  continuous  roaring  like 
the  escape  of  steam  from  a  boiler.  To  this  sound  he  has  since  become 
partially  accustomed.    He  has  never  had  earache,  but  nine  years  ago  there 


1  Labyrinthine  Vertigo,  W.  E.  Eeports,  vol.  v.  p.  34. 

^  Crum-Brown  is  of  the  opinion  that,  in  addition  to  the  other  senses,  the  individ- 
ual possesses  one  of  rotation,  by  which  we  are  able  to  determine  the  axis  about  which 
rotation  of  the  head  takes  place ;  the  direction  of  rotation,  and  its  rate.  In  explain- 
ing some  experiments  performed  by  him,  he  says:  "In  ordinary  circumstances  we 
do  not  wholly  depend  upon  this  sense  for  such  information.  Sight,  hearing,  touch, 
and  muscular  sense  assist  us  in  determining  the  direction  and  amount  of  our  motions 
of  rotation,  as  well  as  of  those  of  translation ;  but  if  we  purposely  deprive  ourselves 
of  such  aid,  we  find  that  we  can  still  determine  with  considerable  accuracy  the  axis, 
the  direction,  and  the  rate  of  rotation.  The  experiments  that  I  have  made  with  the 
view  of  determining  this  point  were  conducted  as  follows:  A  stool  was  placed  on  the 
centre  of  a  table  capable  of  rotating  smoothly  about  a  vertical  axis ;  upon  this  the 
experimenter  sat,  his  eyes  being  closed  and  bandaged  ;  an  assistant  then  turned  the 
table  as  smoothly  as  possible  through  an  angle  of  the  sense  and  extent  of  which  the 
experimenter  had  not  been  informed.  It  was  found  that,  with  moderate  speed,  and 
when  not  more  than  one  or  two  complete  turns  were  made  at  once,  the  experimenter 
could  form  a  tolerably  accurate  judgment  of  the  angle  through  which  he  had  been 
turned.  By  placing  the  head  in  various  positions,  it  was  possible  to  make  the  verti- 
cal axis  coincide  with  any  straight  line  in  the  head.  It  was  found  that  the  accuracy 
of  the  sense  was  not  the  same  for  each  position  of  the  axis  in  the  head  ;  and,  further, 
that  the  minimum  perceptible  angular  rate  of  rotation  varied  also  with  the  position 
of  the  axis.  It  was  also  found  that  considerable  differences  of  accuracy  exist  in  dif- 
ferent individuals." 


AUDITORY   VERTIGO.  141 

was  a  discharge  from  the  left  ear,  but  there  have  since  been  no  other 
symptoms.  He  has  sufiered  for  a  long  time  from  post-pharyngeal  catarrh, 
and  there  is  now  a  catarrh  of  both  Eustachian  tubes.  When  a  young 
man  he  had  secondary  syphilitic  symptoms,  but  denies  having  had  any 
primary  sore.  Sixteen  months  ago,  during  hot  weather,  he  was  seized  in 
the  street  with  dizziness  and  reeling,  and  was  obliged  to  grasp  a  lamp- 
post for  support.  There  was  no  loss  of  consciousness,  and  he  realized 
fully  his  condition  of  helplessness.  He  said  that  he  felt  as  if  he  was  be- 
ing "twirled"  from  right  to  left,  but  did  not  fall.  This  attack  occurred 
before  dinner  (about  11  A.  M. ),  and  his  stomach  was  neither  filled  nor 
completely  empty,  for  he  had  eaten  his  breakfast  at  8  A.  M.  He  was 
perfectly  well  otherwise,  and  the  only  disordered  function  was  that  of  the 
lower  bowels,  for  he  was  constipated.  He  has  had  these  attacks  very 
frequently.  For  the  six  months  following  the  first  attack  of  vertigo  they 
occurred  about  once  a  month,  but  since  then  they  had  been  of  daily  re- 
currence. 

Present  State. — The  patient's  digestive  organs  are  in  good  condition, 
and  his  appetite  is  fair.  He  is  ordinarily  of  constipated  habit,  but  it  re- 
quires but  slight  medication  to  overcome  this.  He  is  of  medium  height, 
weighs  143  pounds,  and  seems  a  well-nourished  man.  His  face  is  some- 
what sufiused  when  he  becomes  excited,  but  he  is  ordinarily  pale.  His 
eyes  convey  an  anxious  expression,  but  the  pupils  are  normal.  His  hair 
is  scanty  and  gray,  but  not  removed  in  patches,  nor  suggestive  of  any  pre- 
vious syphilitic  trouble.  He  has  occasional  headache,  and  still  complains 
of  the  "  roaring  "  noise  on  the  left  side.  Hears  the  tick  of  a  watch  only 
six  inches  from  left  ear,  and  indistinctly  at  any  distance  within  this  limit. 
Watch  tick  heard  at  five  inches  from  right  ear,  but  more  perfectly.  Dr. 
C.  S.  Bull  examined  his  eyes,  and  the  following  is  his  report : — 

20  20 

"  Examination  of  J.  B.    V= :  with  convex  32  spherical  V=-— — - 

40+  40+ 

1 

H  — .     Fundus  perfectly  normal." 
30 

His  attacks  occur  nearly  every  day,  and  seem  to  have  no  relation  with 
the  condition  of  digestion.  These  "  reeling  fits  "  may  take  place  at  any 
time  of  the  day,  last  for  five  or  six  minutes,  and  usually  are  not  so 
sudden  as  to  prevent  him  from  taking  hold  of  the  nearest  lamp-post  or 
railing.  In  a  recent  vertiginous  seizure  he  was  taken  just  as  he  was  about 
to  get  into  a  street  car,  and  would  have  fallen  had  the  conductor  not 
dragged  him  upon  the  step.  He  tells  me  that  he  has  asked  his  wife  to 
"  turn  him  the  other  way  "  when  the  attack  occurs,  and  usually  this  has 
the  effect  of  abating  it.  I  placed  him  upon  large  doses  of  quinine  at  first, 
which  have  decidedly  influenced  the  frequency  and  character  of  the  ver- 
tigo, so  that  he  often  passes  a  week  at  a  time  without  any  seizure.  Bro- 
mide of  potassium  had  been  prescribed  for  him  before  his  visit  by  another 
physician,  but  he  tells  me  that  this  drug  increased  the  dizziness.  The 
phenomena  of  these  attacks  are  the  following :  He  suddenly  feels  light 
headache;  objects  swim  about  him  from  right  to  left  while  he  seems  to 
be  rotated  the  other  way,  and  during  this  period  he  separates  his  feet 
and  braces  himself  The  outlines  of  the  houses,  trees,  and  sidewalks  are 
blurred  and  distorted,  and  after  a  few  minutes  they  suddenly  assume 
their  proper  relations,  and  the  attack  passes  off",  and  he  has  subsequent 
headache. 


142        DISEASES   OF   THE   CEREBRUM    AND   CEREBELLUM. 

Causes. — The  disease  being  directly  due  to  aural  inflammation, aud  the 
causes  of  this  condition,  whether  they  be  exposure,  the  extension  of  other 
inflammatory  processes,  or  the  injudicious  use  of  douches  and  injection, 
are  only  secondarily  productive  of  the  neurosis. 

Pathology. — The  experiments  of  Flourens  and  Goltz^  have  been  the 
basis  for  our  pathological  study  of  Meniere's  disease.  Brown-Sequard '' 
and  Flourens  demonstrated  that  when  the  membranous  canals  of  the 
labyrinth  were  divided,  various  disturbances  of  equilibrium  followed. 
Walter  aud  Lincke  ^  and  others  have  divided  the  horizontal  canals  and 
produced  oscillation  of  the  eyeballs,  swaying  of  the  head  from  one  side 
to  the  other ;  and  have  seen  the  animal  spin  round  like  a  top.  Division 
of  the  posterior  vertical  canal  causes  the  animal  to  toj^ple  over  backwards, 
and  the  head  is  moved  backwards  and  forwards.  When  the  superior  ver- 
tical canals  were  cut  across,  the  animal  pitched  forward.  It  may  be  seen 
that  a  diseased  condition,  not  limited  to  any  particular  spot,  may  produce 
a  couibination  of  these  symptoms. 

Brown  Sequard,  in  speaking  of  the  relation  of  rofary  movements  to 
auditory  irritation,  calls  attention  to  these  familiar  illustrations : — 

"  1st.  Any  one  who  has  received  an  injection  of  cold  water  in  the  ear 
may  know  that  it  produces  a  kind  of  vertigo,  and  that  it  is  diflicult  to  walk 
straight  for  some  time  after  this  irritation.  2d.  A  sudden  noise  makes  the 
whole  body  jump,  particularly  in  old  people,  or  in  persons  attacked  with 
ausemia,  chlorosis,  epilepsy,  chorea,  hysteria,  hydrophobia,  and  in  certain 
cases  of  poisoning ;  in  a  word,  in  all  circumstances  in  which  the  control  of 
the  will  over  reflex  actions  is  lost  or  diminished.  3d.  Vertigo  and  various 
convulsive  movements  in  cases  of  irritation  of  the  acoustic  nerve  have 
been  observed  in  adults  and  children.  Rotatory  movements  have  taken 
place  in  cases  of  suppurative  inflammation  of  the  ear,  and  twice  imme- 
diately after  an  injection  of  nitrate  of  silver."  Ferrier,*  who  has  written 
most  clearly  upon  this  disease,  goes  very  deeply  into  the  subject.  In  the 
normal  state  it  is  necessary  for  tactile,  visual,  and  auditory  impressions  to 
be  unembarrassed,  so  that  the  power  of  equilibriation  may  be  preserved  ; 
but  it  is  of  absolute  importance  that  the  labyrinthine  functions  should  be 
perfect.  It  seems  to  regulate  the  state  of  equilibrium  of  the  individual, 
and  to  preside  over  co-ordination.  The  mechanism  of  the  labyrinthiue 
canals  is  admirably  described  by  Crum-Brown.*  The  sense  of  rotation, 
as  suggested  by  him,  must,  like  other  special  senses,  have  a  special  peri- 
pheral organ,  a  brain  centre,  and  a  connecting  sensory  nerve.  All  experi- 
menters agree  that  the  labyrinth  is  a  special  peripheral  organ,  and  the 
auditory  nerve  is  that  which  conveys  the  peripheral  irritation  to  the  centre. 

'  Pfluger's  Archiv  fiir  Physiologic,  1870,  and  Recherches  snr  les  Propr.  et  les 
Fonctions  dii  Systerae  Nerveux  2d.  ed. 

^  Central  Nervous  System,  Philadelphia,  1860,  and  Experimental  Researches, 
1853. 

*  Wagner's  Handworterbuch  der  Physiol.,  vol.  vi.,  1853,  p.  420  et  seq. 

*  Ferrier  on  the  Faactions  of  the  Brain,  New  York,  1876. 
^  Journal  of  Anatomy  and  Phys.,  May,  1874. 


AUDITORY   VERTIGO.  143 

"The  bony  canals  are  filled  with  liquid,  in  which  float  loose  connective 
tissue,  and  the  membranous  canals  with  the  contained  endolymph.  Rota- 
tion of  the  head  about  an  axis  at  right  angles  to  the  plane  of  a  canal  will 
then  produce,  on  account  of  the  inertia  of  the  liquid,  etc.,  motion  of  the 
contents  relatively  to  the  walls  of  the  canal ;  and  this  may  be  expected  to 
irritate  the  terminations  of  the  nerves  in  the  ampulla.  If  the  rotation  be 
continued  at  a  uniform  rate,  fluid  friction  of  the  endolymph  against  the 
membranous  canal,  and  of  the  perilymph  against  the  membranous  canal, 
and  the  periosteum  will  gradually  diminish  this  relative  motion,  which  will 
at  last  cease.  We  should  therefore  expect,  as  we  have  seen  to  be  the  case, 
that  continued  uniform  rotation  should  be  perceived  less  and  less  strongly, 
and  that  the  sensation  should  at  last  die  away  altogether.  The  time  re- 
quired for  this  equalization  of  the  motion  of  the  canal  and  its  contents  will 
depend  upon  the  rate  of  rotation  and  upon  the  dimensions  of  the  canal 
and  the  amount  of  attachment  of  the  membranous  canal  to  the  periosteum. 
These  latter  conditions  are  not  the  same  in  the  three  canals,  and  there- 
fore we  ought  to  find,  as  we  do,  that  the  rate  at  which  the  sense  of  rotation 
dies  away  is  not  the  same  for  different  positions  of  the  head.  Again,  if 
the  uniform  rotation  is  stopped,  the  contents  of  the  canal  will  continue  to 
move  on,  thus  causing  an  apparent  rotation  in  a  direction  the  reverse  of 
that  of  the  original  rotation,  and  this  also  will  die  away  owing  to  friction." 
The  irritation  of  the  auditory  nerves  which  occurs  is  attended  by  anaemia 
of  certain  parts  of  the  brain,  which  accounts  for  the  reeling,  dizziness, 
nausea,  and  other  symptoms  with  which  we  are  already  familiar. 

Diagnosis. — Gowers,^  in  a  paper  before  the  British  Medical  Associ- 
ation, pointed  out  the  liability  of  its  confusion  with  gastric  trouble.  He 
calls  attention  to  the  fact  that  violent  and  repeated  vertiginous  attacks,  the 
sense  of  movement  or  actual  turning,  tinnitus  aurium,  and  deafness,  are 
more  suggestive  of  the  auditory  origin  than  of  gastric  vertigo.  Gowers' 
cases  were  connected  with  affections  of  smell  and  taste,  and  at  the  same 
time  in  one  there  was  a  gastric  ulcer.  He  made  his  diagnosis  by  the  de- 
tection of  loss  of  function  of  the  right  ear  and  by  one-sided  falling.  It  is 
often  necessary  to  differentiate  from  petit  mal,  from  apoplectic  warnings, 
and  from  general  cerebral  anaemia.  In  the  first  there  is  rarely  vertigo, 
but  there  is  loss  of  consciousness  of  temporary  duration,  and  there  is  some 
convulsive  movement,  though  sometimes  so  slight  as  to  be  unrecognized. 
The  presence  of  aural  disease  is  enough  to  throw  out  of  the  question  the 
other  condition  I  have  named. 

Treatment. — Large  doses  of  quinine  have  been  of  service  in  these 
cases,  and  Chai'cot's^  experience  with  this  agent  is  extremely  gratifying. 

He  recommends  the  energetic  use  of  revulsives  in  vertigo,  the  cautery 
being  applied  over  the  mastoid  bone  three  or  four  times  a  week.  He 
gave  sixty  centigramme  doses  of  quinine  in  one  case  for  a  period  of  two 
months  with  happy  results,  and  a  short  time  after  the  commencement  the 

1  Br.  Med.  Journal,  Aug.  26,  1876. 

'  Lepons  sur  les  Maladies  du  Syst.  Nerv.  No.  4,  p.  321. 


144  DISEASES   OF   THECEREBRUM   AND   CEREBELLUM, 

vertiginous  attacks  ceased.      It  is  necessary  to  give  the  drug  in  large 
doses,  and  at  the  same  time  the  aural  disease  should  not  be  neglected. 

In  the  case  of  "  J.  B."  I  combined  infusion  of  digitalis  with  the  quinine, 
and  obtained  very  good  results.  He  was  also  directed  to  turn  in  an  op- 
posite direction  to  that  caused  by  the  disease.  Subsequent  experience  has 
convinced  me  that  strychnine  is  perhaps  better  than  quinine,  and  I  have 
been  highly  successful  in  relieving  a  case  of  much  greater  violence  in 
which  increasing  doses  of  the  drug  were  administered.  In  this  connec- 
tion it  will  be  well  to  call  attention  to  attacks  of  malarial  vertigo  of  a 
periodic  character  which  are  sometimes  encountered,  and  which  resemble 
auditory  vertigo :  quinine  or  arsenic  is  of  course  indicated. 


INTRACRANIAL    THROMBOSIS.  145 


CHAPTER   IV. 

OCCLUSION  OF  I]N"TKACEANIAL  VESSELS. 

THEOMBOSIS— EMBOLISM. 

The  deprivation  of  an  area  of  greater  or  less  extent  of  its  blood-supply 
constitutes  a  condition  which  has  been  called  by  some  writers  "  Local 
cerebral  ansemia,"  and  it  may  take  place  through  the  existence  of  either 
of  the  above  vascular  states.  Though  very  closely  allied,  these  two 
forms  of  mechanical  obstruction  may  be  defined :  in  one  case,  as  the  local 
formation  of  deposits,  or  morbid  changes  favoring  obliteration  of  blood- 
vessels ;  and  in  the  other,  as  the  lodgment  of  clots,  or  organized  tissues 
which  have  been  brought  from  a  distance.  Their  chief  intei-est  lies  in 
the  fact,  that  it  is  often  difficult  for  us  to  distinguish  the  subsequent 
symptoms  from  those  indicating  an  effusion  of  blood  from  a  ruptured 
vessel ;  that  speech  troubles  are  prominent ;  and  that  the  prognosis  is 
nearly  always  unfavorable.  Thrombosis  and  embolism,  though  usually 
followed  by  many  of  the  same  symptoms,  and  confounded  with  each  other 
by  some  of  the  medical  writers  by  whom  they  were  first  described,  difier 
greatly  in  their  manner  of  occurrence  and  pathology.  The  first,  as  we 
shall  hereafter  see,  is  of  slow  development,  and  is  not  so  serious  in  its  re- 
sults as  embolism,  while  the  latter  condition  is  much  more  grave  in  all 
its  features. 

INTKACRANIAL  THROMBOSIS. 

Any  local  vascular  change  from  the  normal  state  which  favors  the  de- 
position of  fibrine  in  an  intracranial .  vessel,  whether  it  be  an  artery,  a 
vein,  or  sinus,  produces  the  condition  which  is  known  as  thrombosis.  As 
a  consequence,  the  calibre  of  the  vessel  is  narrowed,  and  circulation  of 
blood  is  impeded  therein ;  clots  form,  and  either  from  actual  obstruction 
of  direct  supply  or  by  pressure,  a  region  of  greater  or  less  extent  becomes 
anaemic.  Though  the  arteries  are  more  frequently  the  seat  of  such  an  al- 
teration, the  veins  and  large  sinuses  and  the  capillaries  may  be  plugged 
up  by  clots  which  are  of  local  origin.  The  condition,  however,  last  men- 
tioned is  fortunately  a  very  rare  one,  but  when  it  is  met  with  it  is  a  most 
dangerous  and  alarming  morbid  state. 
10 


146  OCCLUSION   OF   INTRACRANIAL   VESSELS. 

THROMBOSIS   OF   THE   CEREBRAL   ARTERIES. 

Symptoms. — It  is  ii  disease  of  slow  development,  and  may  affect 
several  arteries  simultaneously,  or  but  one.  For  weeks,  or  even  months 
before,  distressing  and  important  evidences  appear,  and  the  patient  may 
present  unmistakable  expression  of  the  cerebral  change,  such  as  head- 
ache, which  is  generally  localized,  confusion  of  ideas,  and  awkwardness 
of  speech,  these  disturbances  being,  usually,  varieties  of  aphasia.  As  the 
disease  advances,  this  trouble  becomes  much  more  pronounced,  and,  in 
place  of  there  being  simply  a  difficulty  in  expressing  a  clearly  originated 
idea,  there  may  be  a  condition  of  amnesia.  Clumsiness  of  speech,  and 
want  of  delicacy  in  articulation  are  followed  by  an  actual  failure  in  re- 
membering words.  Memory  is  also  defective  in  other  things,  and  one 
patient  begins  to  become  stupid  and  listless.  The  next  indication  of  this 
advance  may  be  the  appearance  of  paralysis,  which  is  sometimes  slight,  or 
incomplete,  only  involving  the  muscles  of  the  face  or  eyeballs,  or  there 
may  be  hemiplegia.  Should  the  thrombus  be  seated  in  a  large  artery,  or 
softening  occur,  a  complete  and  lasting  hemiplegia  may  be  produced. 
There  is  rarely  loss  of  consciousness  at  any  time,  and  in  very  few  of  the 
cases  that  recover,  is  there  anything  at  all  like  the  paralysis  following 
cerebral  hemorrhage. 

Recovery  is  generally  to  be  looked  for,  provided  the  vessel  be  not  an 
important  one;  and,  though  like  its  first  cousin,  embolism,  it  may  be  one 
of  the  causes  of  softening,  such  a  termination  is  not  always  to  be  feared, 
xlphasia,  which  is  insisted  upon  by  most  writers  as  a  pathognomonic  sign, 
is  occasionally  absent.  In  one  case  reported,  though  the  left  middle  cere- 
bral was  affected,  there  was  no  aphasia  at  any  time.^ 

The  following  case  is  one  that  came  under  my  observation,  and  is  of 
interest,  because  of  the  seat  of  the  thrombus,  and  the  interesting  character 
of  the  morbid  appearances  : 

L.  C,  aged  22  years,  seamstress;  admitted  into  hospital  October  9, 
1876.  History  from  friend  who  accompanied  her.  The  patient  had  been 
feeling  unwell  for  about  two  months,  having  had  pains  in  her  head  and 
back,  loss  of  appetite,  insomnia,  and  other  troubles.  About  a  week  ago 
the  friend  went  up  to  her  room  to  assist  her  to  dress  for  breakfast.  When 
the  patient  stepped  out  of  bed  she  fell  upon  the  floor,  and  then  first  no- 
ticed that  she  was  completely  paralyzed  on  the  right  side.  The  friend 
knew  nothing  of  the  patient's  antecedents.  Her  husband,  who  was  seen 
subsequently,  stated  that  he  had  left  her  because  she  drank ;  and  that 
after  the  separation  she  went  to  New  York  and  became  a  prostitute. 
Two  years  ago  he  saw  her,  and  at  that  time  she  had  marks  of  syphilis  on 
her  face,  and  her  hair  was  falling  out.  She  conversed  with  him  intelli- 
gibly, but  said  she  was  suffering  from  "  general  debility."  She  had  head- 
ache, pain  in  the  back,  etc.,  and  was  at  this  time  leading  a  very  irregular 
life;  sitting  up  during  the  greater  part  of  the  night,  and  sleeping  only 
a  portion  of  the  day.     She  went  to  Ward's  Island  for  treatment.     The 

^  St.  George's  Hospital  Eeports,  vol.  i.,  1866,  vol.  vi.,  p.  322. 


THROMBOSIS   OF   CEREBRAL   ARTERIES.  147 

following  history  was  taken  by  Dr.  Naylor,  resident  physician  in  hos- 
pital : — 

Oct.  10.  Complete  hemiplegia  of  the  right  side,  limbs  lax,  and  muscles 
flabby  ;  impossible  to  excite  reflex  movements  by  tickling  ;  right  pupil 
irregular,  and  smaller  than  the  left ;  tongue  drawn  to  left  side  when  pro- 
truded, and  when  she  laughs  the  right  side  of  the  face  is  drawn  up.  Con- 
trol over  the  sphincters  good ;  temperature  101°;  patient  aphasic.  When 
asked,  "  How  long  have  you  been  sick  ?  "  replied,  "  Since  Benny ; "  this 
answer  was  given  to  many  questions  asked.  "  What  do  you  hold  in  your 
hand?"  (it  was  a  piece  of  bread.)  "Tobacco."  Seemed  puzzled,  but 
when  reminded  of  its  true  nature  she  brightened  up  and  appeared  to  real- 
ize her  mistake. 

13^/i.  In  about  the  same  condition.  Muscles  of  the  right  arm  and  leg 
do  not  respond  to  the  currents.  When  asked  how  old  she  was,  replied, 
"  So  and  so."  "  What  did  you  work  at  ?  "  "So  and  so.' '  "  What  street 
did  you  live  in  ? "  Appears  puzzled.  "  Was  it  sixteenth  f  seventeenth  f 
eighteenth  f  "  "  Yes."  "  How  long  has  it  been  since  you  last  saw  your 
mother  ?  "  "  You  long  so,  John."  Expression  intelligent,  and  she  seems 
to  understand  all  that  is  said  to  her.  Does  not  hear  so  well  on  left  side, 
with  right  ear  perfectly. 

11th.  Appeared  to  be  suffering  great  pain.  When  asked  to  locate  the 
pain,  she  did  not  attempt  to  do  so.  She  has  passed  no  urine  since  yester- 
day morning.  Has  a  hard  and  swollen  erythematous  spot  on  the  outside 
of  each  knee,  and  two  similar  enlargements  on  each  leg  below.  There  is 
a  hardened  red  spot  over  the  fourth  cervical  vertebra.  All  of  these  parts 
are  painful  to  pressure. 

\dith.  Eight  hand  somewhat  swollen.  6  P.  M.  Is  drowsy  this  evening. 
Appears  to  suffer  pain,  and  places  left  hand  upon  abdomen.  One  pint  of 
straw-colored  urine  containing  no  abnormal  constituents  was  drawn  by  the 
catheter. 

19^/i.  Still  dull  and  drowsy.  Said  nothing  to-day  but  "yes,"  "  no,"  and 
"  well ;"  passed  her  urine  in  bed ;  stupid  and  dull  all  day.  Carotid  on 
right  side  pulsates  very  distinctly. 

list.  Somewhat  brighter  to-day ;  bowels  regular. 

21d.  Relapse  to  stupid  condition ;  passed  urine  in  bed ;  became  choked 
while  eating  some  beef  at  dinner. 

2bth.  Still  absolute  loss  of  power  and  sensation  on  right  side,  and  con- 
tinued drowsiness. 

2Qth.  Involuntary  discharges  of  feces  and  urine. 

21th.  She  brightens  up  after  receiving  nourishment,  but  cries  and  seems 
distressed. 

28i/i.,  2  P.  M.  Nurse  called  the  house  physician,  seeing  that  she  appeared 
to  have  stopped  breathing.  Her  eyes  were  turned  upwards  and  her  lips 
blue,  and  her  pulse  was  very  weak  and  feeble.     Ordered  stimulants. 

Nov.  2d.  Feverish  and  restless ;  temperature  101°  ;  discharges  from  the 
bowels  have  stopped. 

%th.  Complains  of  pain  in  her  thigh  and  legs ;  cries  a  great  deal  ;  re- 
fuses food,  and  appears  to  be  very  much  run  down. 

ith.  Right  pupil  approaching  more  nearly  the  size  of  the  left ;  appetite 
still  good ;  bowels  regular.  Cannot  write  her  name  with  the  left  hand,  but 
makes  a  disorderly  scrawl.  Asked  her  to  repeat  several  words ;  pro- 
nounced "  eggs  "  very  distinctly ;  for  "  cross,"  she  said  "  cork."  7  P.  M. 
Quite  feverish  and  restless ;  temperature  102°. 


14:8  OCCLUSION   OF   INTRACRANIAL   VESSELS. 

ISth.  Has  still  fever ;  temperature  102^.  Ordered  quinine  and  cold 
sponging      She  cries,  and  appears  very  sensitive  when  moved. 

14th.  Slept  well  last  night.  7  P.  M.  Temperature  100^.  Several  in- 
guinal glands  on  the  right  side  are  somewhat  enlarged  and  painful  on 
pressure. 

22d.  Complains  of  great  pain  at  the  attachment  of  the  adductors  to 
femur. 

The  month  of  December  was  passed  without  anything  occurring  of  spe- 
cial note.  The  patient  grew  much  more  feeble  ;  there  was  no  improve- 
ment in  the  paralysis,  and  she  became  reduced  to  a  shadow.  Tlie  tempera- 
ture continued  elevated,  and  she  was  restless  and  delirious  at  times.  Of 
course  the  burden  of  her  delirium  consisted  of  two  or  three  words,  which 
were  repeated  over  and  over. 

Jan.  8,  1877.  Dr.  Naylor  was  called  to  see  the  patient  at  4  o'clock  P. 
M.  He  then  noticed  some  fibrillary  contraction  about  the  right  angle  of 
the  mouth,  with  an  occasional  spasm  of  the  upper  lip,  when  it  would  be 
drawn  up  with  the  wing  of  the  nostril.  Eyes  closed,  pupils  more  con- 
tracted than  usual,  face  flushed  and  head  hot ;  temperature  in  axilla  101 1°. 
When  left  foot  was  pricked  she  turned  it  up ;  pulse  too  rapid  to  count ; 
heart's  action  tumultuous.  Tr.  digitalis,  gtts  xv.  5  o'clock  P.  M.  Spasm 
of  lip  still  continues ;  lies  on  her  back  with  eyes  closed,  and  gives  no  evi- 
dence of  pain  when  any  part  of  the  body  is  pricked ;  pulse  in  same  state. 
6  o'clock  P.  M.  Breathing  heavily ;  »£yelids  closed  and  eyes  turned  up- 
ward ;  pupils  do  not  contract  to  light,  but  lids  contract  slightly  when  con- 
junctiva is  touched  ;  reflex  irritability  very  much  impaired;  j^ulse  100  ; 
temperature  102°  7  o'clock  P.  M.  Spasm  of  mouth  has  ceased ;  respi- 
ration very  slow  and  feeble ;  pulse  80  ;  temperature  102^.  10  o'clock 
p.  M.  Mucous  rales  heard  over  whole  chest.  12  o'clock  A.  M.  Patient 
remains  unconscious.  2  o'clock  P.  M.  Patient  still  breathes  slowly  and 
feebly ;  small  amount  of  frothy  mucus  comes  out  of  her  mouth ;  patient 
remained  in  this  condition  until  death,  10  A.  M.,  9th  instant. 

Autopsy. — Head :  dura  mater  normal ;  sinuses  empty ;  moderate  eflTu- 
sion  into  arachnoid  cavity  ;  pia  mater  intensely  congested ;  left  middle 
cerebral  artery  about  ^  inch  from  its  origin  occupied  by  a  firm  thrombus  ; 
beyond  this  the  artery  was  thin,  ribbon-like,  scarcely  percei^tible,  and 
finally  lost ;  membranes  readily  detached  from  the  brain,  leaving  the  sulci 
gaping  widely  over  the  under  surface  of  anterior  lobe,  left  side  about  third 
frontal  convolution  and  island  of  Reil.  In  detaching  the  membranes  por- 
tions of  brain-substance  were  removed  with  them,  leaving  an  almost  pul- 
taceous  mass  exposed  ;  indeed  the  whole  of  under  surface  of  anterior  lobe 
was  much  softened,  but  this  was  most  marked  near  the  lateral  border ; 
under  surface  of  middle  lobe  slightly  softened  ;  superior  and  lateral  as- 
pect of  anterior  and  middle  lobes  from  fissure  of  Rolando  forwards  was  in 
a  very  softened  condition,  breaking  down  under  the  least  pressure,  of  a 
pale  yellowish-gray  color,  in  marked  contrast  with  other  parts  of  the  brain, 
which  on  section  showed  very  numerous  puncta  vasculosa,  and  were  of  the 
normal  color.  Thalamus  opticus  somewhat  softer  than  that  of  the  right 
side ;  corpus  striatiim  much  softened  and  of  a  yellowish  color.  Thorax  : 
lungs  cedematous,  and  poured  out  an  abundance  of  mucus  on  section. 
Heart :  insufficiency  of  mitral  valve ;  no  vegetations  noticed ;  left  ven- 
tricle entirely  filled  by  a  firm  white  clot  entangled  in  chorda;  teudinae  and 
projecting  into  aorta ;  abdomen,  kidneys,  liver,  and  spleen  much  con- 
gested. 


THROMBOSIS   OF   CEREBEAL   ARTERIES.  149 

Causes. — Men  are  moi-e  often  subject  to  arterial  thrombosis  than 
women  or  children,  though  we  find  the  great  number  of  cases  of  throm- 
bosis of  the  sinuses  to  be  among  women,  and  this  perhaps  due  to  the  ten- 
dency of  this  sex  to  chlorosis. 

Gintrac  considers  very  young  children  to  be  subject  to  venous  throm- 
bosis. Of  37  cases  seen  by  him,  14  were  among  infants ;  but  arterial 
thrombosis  is  a  condition  peculiar  to  advanced  life,  and  instances  before 
middle  age  are  not  at  all  common  unless  they  be  of  a  specific  nature. 
The  exciting  causes  are  numerous,  but  it  may  be  assumed  in  nearly 
every  instance  that  the  blood  is  in  a  state  of  hyperinosis  as  a  consequence 
of  acute  disease,  such  as  rheumatism  or  pneumonia.  Excessive  heat  is 
very  often  a  cause.  Dickinson^  gives  four  cases,  in  two  of  which  heat 
was  the  cause,  in  one  other  intemperance,  and  in  the  fourth  violent 
vomiting, 

In  many  of  these  patients  there  is  old  heart  disease  with  some  enfeebled 
action  of  that  organ.  The  basilar  artery,  which  receives  its  blood  from 
the  vertebral  arteries,  may  be  the  seat  of  a  clot  at  its  remote  end  when 
heart  force  is  preternaturally  weak,  but  this  is  a  rare  form  of  the  disease. 
I  have  already  spoken  of  peripheral  phlegmatous  troubles,  and  it  is  only 
necessary  to  call  attention  to  the  danger  which  may  arise  from  carbuncle. 
The  puerperal  state  favors  the  formation  of  thrombi,  and  just  as  phleg- 
masia alba  dolens  is  brought  about,  so  may  the  thrombosis  of  the  cerebral 
arteries  be  produced.  The  graver  variety  of  intracranial  thrombosis  may 
be  produced  by  internal  or  external  cause.  Lancereaux  collected  89 
cases,  30  of  which  were  connected  with  caries  of  some  of  the  cranial  bones, 
and  24  with  otitis.  In  one-half  of  these  cases  there  were  multiple  ab- 
scesses of  the  brain. 

In  conclusion  I  would  allude  to  the  possibility  of  traumatic  origin,  a 
variety  of  blood-states,  and  pressure  from  intracranial  tumors,  exostoses, 
and  thickened  meninges. 

Morbid  Anatomy  and  Pathology. — You  Dusch,  Paruum,^ 
Grissole,^  Zahn,  and  a  host  of  observers  have  devoted  themselves  to  the 
study  of  this  subject,  and  since  the  original  observations  of  Kirkes''  were 
published  in  1852,  which  were  devoted  to  the  pathology  of  thrombosis 
as  well  as  embolism,  a  great  deal  has  been  written.  Parnum  and 
Burrowes^  both  experimented  by  injecting  substances  into  the  circula- 
tion, and  Burrowes  probably  relates  the  earliest  case  of  recognized  throm- 
bosis. 

Zahn  gives  the  following  concise  description  of  the  pathological 
process  which  attends  the  production  of  the  thrombus.  "  The  intensity 
and  the  duration  of  the  injury,  together  with  the  previous  condition  of 
the  individual,  determine  the  durability  of  the  clot.     The   process  of 

^  Loc.  cit: 

2  Virchow's  Archiv,  xxv.  3—6,  pp.  308—328,  433,  530,  1862. 

3  Pathol.  Intern.;  p.  247. 

*  Med.  Chir.  Trans,  1852. 
5  Med.  Gaz.,  vol  xvi.  1834-5, 


150  OCCLUSION  OF   INTRACRANIAL  VESSELS. 

formation  is  the  following.  Colorless  blood-corpuscles  adhere  to  a  part 
of  the  intima  denuded  by  an  injury  of  its  endothelium.  They  accumulate 
there,  form  a  ring-like  obstruction,  and  gradually  the  clot  obstructs  the 
vessel  altogether.  If  the  injury  be  slight,  and  the  nutrition  of  the  indi- 
vidual unimpaired,  the  current  of  blood  soon  breaks  through  the  blood- 
clot  and  carries  along  the  flakes  of  the  colorless  blood-corpuscles.  The 
normal  condition  is  soon  restored.  If  the  injury  of  the  vessel  be  more 
severe,  and  the  surrounding  tissue  already  in  a  state  of  irritation,  the 
thrombus,  whilst  forming  in  the  same  way  as  described,  is  firmer  and 
larger.  The  obstruction  is  more  complete,  and  lasts  for  twenty-four 
hours  and  more ;  after  that  period  the  thrombus  begins  to  disintegrate 
into  granular  fibrine,  the  outlines  of  the  blood-corpuscles  composing  the 
thrombus  cease  to  be  visible,  and  thus  an  uninterrupted  circulation  is  re- 
established."^ In  more  serious  trouble  the  detached  clots  maybe  the 
nuclei  of  larger  ones  in  the  sinuses  if  the  condition  of  the  arterial  walls 
be  such  as  to  favor  more  extended  formation  of  thrombi  so  that  the 
vessels  become  entirely  occluded. 

The  consequence  of  arterial  occlusion  is  the  formation  of  an  extended 
clot  which  blocks  up  the  vessel  more  fully,  and  consequent  ischsemia  of 
distal  parts.     Through  the  agency  of  outside  vessels  collateral  circulation 
is  generally  established  in  a  short  space  of  time.     If,  however,  the  ana- 
tomical site  be  such  as  to  interfere  with  this  provision  of  nature,  softening 
or  tardy  degeneration  will  ensue.     This  softening,  when  it  follows,  is  ex- 
pressed by  a  series  of  changes,  which  occur  about  as  follows  :  Red  soften- 
ing in  from  24  to  48  hours,  while  the  yellow  change  does  not  take  place 
until  after  14  days.     But  of  this  condition  of  affairs  I  will  speak  in  a  sub- 
sequent chapter.     The  carotid  arteries  and  their  termination  are  more 
often   affected,  and  basilar  vertebrals,  anterior   cerebral,  and  posterior 
communicating  come  next,  in  the  order  that  I  have  given  them.     The 
pathological  processes  in  the  second  form  of  intracranial  thrombosis,  viz., 
that    affecting  the   sinuses  and  veins,  are   much    more  gross.     Either 
through  sluggish  circulation  of  the  blood  on  the  part  of  a  weak  heart, 
pressure  upon  a  sinus,  or  unusual  density  of  the  blood,  coagulation  oc- 
curs, the  arterial  flow  is  interfered  with,  a  part  of  the  brain  is  deprived 
of  blood,  and  serum  is  eff'used.     If  the  disease  be  due  to  outside  causes, 
there  may  be  an  extension  of  inflammatory  actioii  from  without  in  the 
manner  I  have   described.     By  an  extension  of  thrombosis,  a  form  of 
meningitis  resembling  tubercular  meningitis  may  be  produced.     Several 
of  these  cases  have  been  seen  by  Scuch.'    An  artery  which  is  the  seat  of 
a  thrombus  presents  these  appearances  :— The  inner  coat  is  rough  and 
perhaps   corrugated  ;  the  artery  as  a  whole  may  be  hard  and  discolored, 
with  diminution  in  calibre  and  a  deposition  of  recent  or  ancient  date,  in 
which   latter  case  it  will  be  pale  and  tough,  while  atheroma  is   not  un- 


1  Virchow's  Archiv,  Band  Ixii.,  Heft  1,  Nov.,  1874. 

2  Verhandlung  dur  Wurz.,  p.  Med.  Geselschaft,  viii.  179. 


THROMBOSIS   OF   SINUSES   AND   VEINS.  151 

commonly  present.  Fox^  has  observed  that  the  part  of  the  plot  ad- 
herent to  the  inner  coat  of  the  vessel  is  much  more  dense  than  that 
nearest  the  centre.  When  the  capillaries  are  implicated,  they  are  gener- 
ally found  to  be  hard  and  calcareous.  In  thrombosis  of  the  large  sinuses 
or  veins,  the  morbid  appearances  are  much  more  striking.  The  thrombi 
are  large,  and,  if  old,  of  a  gray  color,  and  it  is  not  rare  to  find  pus- 
effusions  of  serum  into  neighboring  parts,  and  perhaps  some  meningitis. 
Von  Dusch  has  collected  57  cases,  which  are  given  by  Fox.^  In  32  the 
thrombosis  resulted  from  gangrenous,  erysipelatous,  and  other  inflamma- 
tions of  the  body  (chiefly  of  head).  In  15  it  appears  to  have  resulted 
from  asthenic  circulation.  In  6  cases  nothing  positive  could  be  ascer- 
tained. 

Diagnosis. — There  are  very  few  conditions  with  which  that  under 
consideration  may  be  confounded.  When  we  remember  that  in  throm- 
bosis the  development  of  symptoms  is  gradual,  the  loss  of  speech  incom- 
plete, and  primary ;  and  in  cerebral  hemorrhage  the  onset  is  sudden,  the 
aphasia  is  secondary  to  a  loss  of  consciousness,  and  the  paralysis  more 
marked,  the  diagnosis  from  this  disease  is  not  so  difficult.  Doubts  may 
arise  in  our  minds  when  we  are  to  decide  whether  or  not  the  case  before 
us  is  one  of  thrombosis  or  uncomplicated  softening.  Thrombosis  is  rarelv 
attended  by  marked  elevation  of  temperature,  while  the  opposite  is  to  be 
observed  in  cerebritis,  which  presents  as  symptoms  trembling  and  per- 
haps muscular  rigidity.  The  psychical  symptoms  are  also  more  strongly 
marked.  The  more  serious  form  can  be  diagnosed  by  the  coexistence  of 
other  conditions  which  may  favor  its  origin. 

Treatment. — The  chief  indication  seems  to  be  :  The  improvement 
of  the  condition  which  influences  the  j)roduction  of  the  thrombus.  If 
arterial  tension  be  at  all  weak,  we  may  combine  digitalis  and  iron,  give 
tonics  and  improve  the  patient's  general  condition  by  good  food  and  stimu- 
lants. Nature  will  arrange  the  process  of  collateral  blood-supply,  and 
we  may  aid  her  by  enforcing  rest  and  quiet. 


THROMBOSIS  OF  SINUSES  AND  VEINS. 

When  a  large  sinus  or  vein  is  involved,  the  resulting  symptoms  are 
much  more  complex  and  difficult  to  diagnose. 

Lancereaux,^  who  has  written  quite  extensively  about  this  form  of  dis- 
ease, has  divided  into  two  grades,  in  regard  to  the  variety  of  morbid 
action.  One  of  these  is  inflammatory,  the  other  is  non-inflammatory. 
The  first  form  is  dependent  upon  the  extension  of  some  inflammatory  pro- 
cess, usually  from  the  ear,  while  the  other  is  attended  by  coagulation  of 
the  blood  in  sluggish  circulation. 


1  Path.  Anat.  of  the  Nervous  Centres,  p.  32. 

^  Loc.  cit.,  p.  35. 

^  De  la  Thrombose,  etc,  Paris,  1862. 


152  OCCLUSION   OF   INTRACRANIAL   VESSELS. 

Von  Dusch^  does  not  agree  with  him,  but  Tonnele,  quoted  by  Grisolle,'* 
makes  the  same  varieties  as  Lancereaux. 

The  seats  of  this  pathological  condition  are  the  longitudinal,  lateral, 
basal  sinuses,  and  the  large  veins  communicating  therewith.  Bastian' 
alludes  particularly  to  the  longitudinal  sinus  as  the  most  common  seat 
and  describes  the  tendency  to  plugging  up  of  the  cerebral  veins  on  both  sides. 

As  I  have  said,  the  symptoms  are  very  obscure,  but  in  every  case  we 
may  consider  them  to  be  the  indication  of  pressure.  Headache,  delirium, 
coma,  convulsions,  ocular  troubles,  and  generally  death  in  a  very  short 
space  of  time  mark  the  course  of  the  disease.  Mr.  Tuckwell*  reports  a 
case  which  is  a  representative  of  the  anaemic  form.     It  is  as  follows  : — 

Eliza  C,  set.  16,  was  admitted  to  Radcliffe  Infirmary  on  the  20th  day 
of  April,  1871.  She  ceased  working  a  month  before  on  account  of  pal- 
pitations, shortness  of  breath,  weakness,  irregularity  of  the  menses,  etc. 
Two  weeks  before  admission  she  began  to  suffer  from  violent  headache. 
She  never  had  fits.  A  condition  of  decided  chlorosis  was  diagnosed. 
There  was  a  systolic  murmur  at  base  and  venous  murmur  in  the  neck  ; 
nothing  eise  abnormal  was  detected.     She  was  put  to  bed. 

Ajjril  21.  She  sat  up,  but  it  was  noticed  that  she  lolled  about  in  a 
strange  manner,  and  seemed  stupid.  Her  right  hand  and  arm  were  weak, 
and  she  could  not  raise  them  to  shake  hands.     Headache  still  severe. 

24ih.  Remained  in  same  apathetic  state ;  the  paralysis  of  arm  had  in- 
creased, and  she  could  not  move  fingers  or  hand  at  all ;  headache.  She 
became  comatose,  and  died  after  the  visit  of  Dr.  Tuckwell  and  his  col- 
league. Dr.  Palmer. 

Autopsy  twenty-four  hours  after  death.  On  removing  skullcap,  the 
dura  mater  covering  right  hemisphere  was  found  to  be  of  a  dark  color, 
and  the  longitudinal  sinus,  when  examined,  was  found  half  way  blocked 
up  by  a  firm  white  blood-clot  of  some  age.  Cerebral  veins  on  the  surface 
of  the  middle  and  posterior  part  of  right  hemisphere  were  all  occluded 
by  dark  clots.  On  removing  the  brain,  blood  was  found  effused  in  the 
right  middle  cerebral  fossa,  extending  down  into  the  spinal  canal. 

Lateral  and  basal  sinuses  were  filled  with  clots  of  some  age.  The  pons 
and  medulla  were  covered  by  a  clot  of  recent  date.  General  softening  of 
the  brain  was  observable,  the  optic  thalami  and  corpora  striata  being  par- 
ticularly affected.  The  arteries  were  all  healthy,  as  well  as  the  bone  about 
the  sinuses. 

Another  case  is  reported  by  Dr.  Tuckwell,  which  presented  sj^mptoms 
which  were  very  much  like  those  of  his  own  case. 

Von  Dusch^  has  spoken  of  epistaxis  with  thrombosis  of  the  longitudinal 
sinus  as  a  common  symptom,  and  Meissner  has  called  attention  to  grind- 
ing of  the  teeth,  profuse  diarrhoea,  and  exhaustion,  together  with  certain 
changes  in  the  configuration  of  the  head.     In  children  he  has  found  de- 

1  Zeits.  fiir  Ration.  Med.  B.  vii.,  1359,  p.  11. 

2  Op.  cit.,  tome  ii.  p.  240. 

^  Paralysis  from  Brain  Disease,  etc.,  p.  22. 

*  St.  Bartholomew's  Hospital  Reports,  vol.  x.,  1874,  p.  35. 

5  Loc  cit. 


THROMBOSIS   OF   SINUSES   AND   VEINS.  153 

pressed  fontanelles,  lapping  of  cranial  bones,  and  unequal  distension  of 
the  jugular  veins.  Metastatic  abscesses,  indicated  by  local  symptoms, 
have  been  found  by  many  observers.  Lancereaus  estimates  tbat  nearly 
balf  of  all  the  cases  are  thus  complicated.  I  have  seen  one  case  where 
erysipelas  was  undoubtedly  the  cause  of  the  cerebral  thrombosis,  and 
after  death  the  great  sinuses  were  found  to  be  filled  with  semi-purulent 
matter,  and  there  were  abscesses  in  the  liver  and  other  parts  of  the  bod  y. 
These  cases  are  not  so  exceptional  as  they  are  generally  supposed  to  be, 
but  diagnosis  before  death  is  rarely  made. 

An  autopsy  made  at  the  New  York  Hospital  by  Dr.  Amidon,  who 
kindly  invited  me  to  be  present,  revealed  the  following  beautiful  evi- 
dences of  thrombosis  of  the  cerebral  sinuses  which  followed  septicaemia  : 

The  boy  had  died  after  several  days'  illness,  the  original  injury  being 
a  compound  fracture  of  the  bones  of  the  left  leg.  The  autopsy  was  held 
on  September  15th,  the  day  of  his  death. 

The  liver,  kidneys,  and  lungs  showed  evidences  of  acute  congestion,  and 
the  heart  contained  two  ante-mortem  clots ;  one  occupying  the  right  auri- 
cle, and  the  other  the  right  ventricle.  The  lungs  were  carefully  exam- 
ined, and  a  pyramidal  infarction  was  found  at  the  border  of  the  inferior 
lobe  of  the  left  lung.  The  head  was  opened,  and  the  dura  mater  was  found 
to  be  quite  healthy,  except  in  the  superior  longitudinal  sinus,  which  was 
almost  completely  filled  with  a  well-organized  thrombus  of  a  pale  color. 
One  of  the  large  descending  veins  in  the  parietal  region  was  occluded, 
and  when  the  dura  mater  was  removed,  a  large  pouch,  filled  with  limpid 
and  perfectly  clear  serum,  was  found  beneath,  which  pressed  upon  the  pa- 
rietal convolutions  just  posterior  to  the  fissure  of  Rolando.  This  was 
beneath  the  arachnoid.  At  no  other  point  was  there  any  abnormal  col- 
lection of  fluid,  and  in  no  place  was  there  any  evidence  of  structural 
changes  of  the  brain-substance  proper.  The  lateral  sinuses  were  partially 
filled  with  thrombi,  and  contained  some  very  fluid  blood.  The  left  pe- 
trosal vein  was  empty,  as  were  others  which  were  higher  up.  No  arterial 
occlusion  was  found.  The  patient  had  died  suddenly  in  convulsions 
with  coma. 

Causes. — Blows  upon  the  head,  injuries  of  various  kinds,  extension 
of  otitis,  intemperance,  and  the  causes  I  have  already  enumerated, 
may  be  mentioned.  There  seems  to  be  no  special  dependence  upon 
age  or  sex,  though  it  may  be  said  that  most  of  the  cases  occur  during 
adult  life. 

What  I  have  already  said,  and  the  excellent  cases  of  Tuckwell,  which 
have  been  presented,  render  it  unnecessary  to  say  more  about  the  morbid 
anatomy,  jjathology  or  diagnosis. 

In  regard  to  the  prognosis,  there  can  be  no  question.  It  is  about  as 
bad  as  it  can  well  be.  As  to  treatment,  the  most  we  can  do  is  lio  build  up 
our  patient,  and  reduce  the  danger  of  external  disease  by  favoring  a  free 
escape  of  pus  if  the  original  disease  be  otitis,  and  there  be  an  accumula- 
tion. We  may  employ  local  cold  and  derivatives,  but  even  these  do  little 
good  after  the  disease  is  recognized. 


154  OCCLUSION  OF   INTRACRANIAL   VESSELS. 


EMBOLISM  OF  THE  CEREBRA.L  VESSELS. 

The  cerebral  arteries  and  capillaries  are  alike  subject  to  this  form  of 
mechanical  obstruction,  but  the  former  are  perhaps  the  most  common  seat 
of  the  lodgment  of  fibrinous  plugs.  The  little  bodies  which  are  forced 
into  the  vessels  are  always  from  some  other  part  of  the  system,  and  are 
not  formed  in  the  vessel,  as  is  the  case  in  thrombosis. 

Embolism  also  differs  from  thrombosis  in  the  fact  that  the  latter  is 
always  developed,  and  attended  by  gradual  narrowing  of  the  vessel ; 
while  the  condition  under  consideration  is  a  sudden  accident,  and  may 
occur  in  a  perfectly  healthy  vessel ;  the  converse  is  the  rule  in  throm- 
bosis. 

Symptoms. — Unless  there  is  previous  acute  endocarditis,  there  will 
seldom  be  any  warning,  the  patient  being  suddenly  stricken  down  as  the 
little  plug  is  violently  forced  into  some  vessel  of  the  brain.  There  may 
even  be  no  loss  of  consciousness,  though  this  is  the  exception.  Uncon- 
sciousness invariably  occurs  when  a  large  embolon  plugs  up  some  such 
artery  as  the  middle  cerebral ;  but  if  the  embolon  be  small,  and  the  ar- 
tery occluded  is  one  concerned  to  a  very  limited  extent  in  the  vascular 
supply  of  the  cerebrum,  the  unconsciousness  may  be  but  transitory,  and 
psychical  symptoms  of  slight  moment  will  constitute  the  sole  indications  of 
confused  mental  activity. 

The  eyes  are  sensitive  to  light,  the  pulse  is  small  and  rapid,  and  there 
is  usually  pallor.  There  are  no  indications  of  pressure,  no  stertor,  no  tu- 
multuous respiration,  nor  full  pulse,  and  the  pupils  are  either  dilated  or 
irregularly  contracted. 

If  the  heart  be  auscultated,  various  murmurs  or  friction-sounds  will  in 
many  cases  be  heard.     Mitral  murmurs  are  perhaps  the  most  common. 

Paralysis  taking  the  form  of  complete  or  incomplete  hemiplegia  is  the 
result  of  such  sudden  arterial  occlusion. 

Special  facial  muscles  may  be  those  affected,  or  various  modifications  of 
sensation,  such  as  anaesthesia  or  hypersesthesia,  may  be  detected,  but  rigid- 
ity or  contractures  are  rarely  present  unless  there  is  secondary  disorgan- 
ization, and  they  are  never  seen  during  the  early  stages.  Vertigo  is  a 
disagreeable  and  common  symptom,  and  is  sometimes  attended  by  cere- 
bral vomiting.  Of  course  aphasia  is  an  almost  invariable  consequence  of 
embolism,  as  the  middle  cerebral  artery  is  so  commonly  occluded.  This 
aphasia  is  of  variable  extent,  and  is  ataxic  or  amnesic,  but  generally  the 
latter.  On  the  other  hand,  the  patient  may  be  simply  stupid  and  taciturn, 
refusing  to  answer,  or  he  may  be  troubled  with  a  light  form  of  clumsi- 
ness or  slowness  of  speech.  The  headache,  which  is  subsequent  to  the  loss 
of  consciousness,  is  coincident  ordinarily  with  the  re-establishment  of  col- 
lateral circulation,  and  if  further  changes  occur  there  may  be  intense 
head-pain,  delirium,  mania,  or  symptoms  indicative  of  softening.  The 
duration  of  this  stage  varies  greatly.  I  have  seen  examples  where  the 
symptoms   were  trifling   and   transitory,   such   as   headache,   awkward 


EMBOLISM    OF    CEREBEAL    VESSELS.  155 

speech,  and  paralysis  of  one  arm.  rapidly  disappearing.  Other  cases  are 
correspondingly  serious.  Mr.  Shaw^  reports  a  case  which  proved  fatal  in 
twenty-four  hours,  and  others  have  detailed  examples  in  which  death  en- 
sued in  from  thirty-six  to  forty-eight  hours. 

It  is  very  common  to  find,  at  the  same  time,  symptoms  indicative  of 
embolism  of  other  organs.  The  spleen,  lungs,  and  organs  which  receive 
a  large  supply  of  blood,  or  are  in  the  direct  line  of  arterial  supply,  are  apt 
to  be  involved  as  well  as  the  brain.  It  rarely  happens  that  two  or  more 
cerebral  arteries  are  simultaneously  plugged.  In  such  cases  the  symptoms 
are  complicated.  One  case  is  recorded  in  which  both  middle  cerebral 
arteries  were  occluded,  and  the  following  case  reported  by  Sokolowski'^  is 
an  example  of  coexisting  splenic  and  cerebral  embolism : — 

The  patient  was  a  servant,  married,  aged  23,  who  had  always  menstru- 
ated regularly,  except  when  she  was  pregnant  second  year  before,  and 
then  gave  birth  to  a  healthy  child.  Her  health  had  been  ordinarily  good. 
Four  days  before  her  admittance  to  the  hospital  she  had  suffered  from 
alternate  chills  and  heat,  with  headache  and  constipation.  On  admis- 
sion her  pulse  was  100  ;  temperature,  102.6°.  Heart  friction  sound 
at  apex,  but  nowhere  else.  Passed  53  oz.  urine  in  24  hours ;  sp.  gr. 
1025. 

October  ISth.  She  suddenly  became  paralj^zed  on  the  right  side,  lost  all 
power  of  speech,  and  only  moaned  and  cried  in  a  frightened  manner.  The 
third  day  after,  acute  idiopathic  endocarditis  was  diagnosed.  The  right 
ventricle  was  found  to  be  greatly  enlarged.  Temp.  101.2°  ;  pulse  100. 
After  paralysis  she  lost  hearing  in  the  right  ear  ;  pupils  were  normal ;  left 
side  of  mouth  was  drawn  up.  Anseesthesia  of  paralyzed  parts.  Urine  and 
feces  passed  unconsciously.  Spleen  tender  and  enlarged.  An  additional 
diagnosis  was  now  made.  Embolism  of  left  middle  cerebral  artery,  and 
embolism  of  splenic  artery.  The  loss  of  speech  was  peculiar.  She  was 
unable  to  articulate  at  all,  though  there  was  sufficient  evidence  of  mental 
activity  and  originating  power,  so  she  communicated  with  her  friends  by 
signs.  The  paralysis  had  begun  to  disappear  in  the  right  leg  below  the 
knee,  and  she  could  move  her  foot  slightly.  The  temperature  on  the  first 
day  was  102.2°  ;  pulse  90.  In  the  evening,  104.8°  ;  pulse  100.  On  the 
second  day,  Oct.  14,  there  was  much  improvement.  The  morning  tem- 
perature was  102.8°,  and  the  evening  103.8°. 

15th.  All  paralysis  and  alalia  have  vanished.  She  is,  however,  ex- 
tremely weak.  Daring  the  next  two  or  three  days  a  diarrhoea,  loss  of 
appetite,  and  considerable  increase  of  tenderness  over  the  spleen  appeared. 

28^/i.  35  oz.  of  urine  were  passed,  which  contained  albumen,  hyaline 
casts,  and  urates  in  abundance. 

November  10th.  She  has  grown  gradually  worse,  is  no  longer  able  to 
answer  questions,  but  repeats  words  and  sentences  over  and  over.  There 
is  marked  loss  of  memory.  The  fever  has  greatly  increased,  the  evening 
temperature  being  105.2°  ;  pulse  120,  and  quite  thready.  There  are  evi- 
dences of  bronchitis  and  pulmonary  difficulty.  Urine  greatly  decreased 
in  quantity,  and  albumen  increased  ;  tongue  quite  dry. 

^  Trans,  of  Path.  Soc.  of  London,  vol.  iv. 
2  Deutsche  Med.  Wocli.,  Dec.  15,  1875. 


156  OCCLUSION   OF    INTRACRANIAL   VESSELS. 

20//!.  She  died.  There  was  extensive  hypostatic  pneumonia ;  conscious- 
ness remained  to  end. 

Autopsy. — Arteries  at  base  healthy,  except  middle  cerebral  on  left  side. 
This  contained  a  semi-transparent  embolism  of  cartilaginous  consistency. 
Right  side  of  brain  healthy,  though  pale.  The  left  side  in  the  same  con- 
dition, except  at  the  island  of  Reil,  and  gray  matter  of  lenticular  nucleus, 
■which  were  small,  hard,  and  yellow,  and  showed  evidences  of  softening 
and  subsequent  cicatrization.  The  heart  was  enlarged,  and  yellow  spots 
were  found  beneath  the  endocardium.  The  edges  of  the  mitral  valves 
were  thickened  and  covered  with  coagula.  The  spleen  enlarged, "  blocked," 
and  the  splenic  artery  occluded. 

Cases  have  been  reported  where  embolism  followed,  or  was  connected 
with,  chorea,  and  this  connection  has  been  made  use  of  in  the  explanation 
of  the  pathology  of  the  latter  disease.  One  of  these  cases,  seen  by  Murchi- 
son,^  is  worthy  of  mention. 

The  patient,  a  boy  14  years  old,  had  suffered  from  chorea  when  seven 
years  old,  from  which  he  recovered.  Two  weeks  before  he  died,  irregular 
choreic  movements  appeared,  connected  with  a  bellows  murmur  at  the 
left  apex.  "When  seen,  June  12th,  the  pulse  was  120  ;  temperature  102°. 
There  was  a  pericardial  friction  sound,  but  no  pain  in  joints  or  other 
symptoms  of  rheumatism  or  endocarditis. 

June  28.  Sudden  unconsciousness,  head  drawn  to  right  side,  extreme 
rigidity,  twitching  on  right  side.  Pulse  145.  Pupils  normal  and  equal, 
but  subsequently  contracted  ;  no  paralysis.  Died  June  29.  Vegetations 
on  mitral  valves,  spleen  containing  emboli.  Left  vertebral  and  left  in- 
ternal carotid  arteries  blocked  by  pale,  firm,  and  easily  detached  coagula ; 
left  hemisphere  considerably  softened.  Examination  revealed  no  small 
emboli  in  capillaries. 

A  case  of  my  own,  showing  an  accident  which  may  occur  in  the  course 
of  certain  acute  diseases,  seems  to  me  to  be  of  sufficient  interest  to  present, 
as  it  may  call  attention  to  a  cause  of  death  which  is  probably  sometimes 
overlooked. 

Mr.  N.,  ret.  35,  a  stout,  full-blooded  man  of  good  habits  and  no  vices, 
took  to  his  bed  on  the  25th  of  June,  1874. 

He  had  contracted  a  "  bad  cold  "  at  the  theatre,  and  the  next  day  was 
seized  with  pain  in  the  left  side,  was  chilly  and  uncomfortable,  and  when 
I  saw  him  on  the  evening  of  the  same  day,  he  had  a  violent  headache. 
His  skin  was  hot,  and  his  pulse  hard  and  rapid.  The  thermometer  indi- 
cated a  temperature  of  101°  ;  pulse  122.  At  the  base  of  the  left  lung 
crepitant  rales  were  heard.  Flaxseed  poultices  were  applied,  and  quinine 
and  other  remedies  administered.  For  the  next  four  or  five  days  the 
lungs  underwent  consolidation,  and  nearly  all  of  the  physical  signs  con- 
nected with  the  different  stages  of  pneumonia  were  observed.  The  most 
marked  of  these  was  a  high  temperature,  which  ranged  between  103°  and 
105°  for  six  days.  Resolution  was  slow,  and  but  a  few  sputa  were  brought 
up,  but  the  temperature  had  fallen  to  some  extent.  I  was  sent  for  in  haste 
on  the  evening  of  the  fourteenth  day,  an  hour  after  my  ordinary  visit,  to 

^  London  Path.  Soc.  Trans.,  vol.  xxii. 


EMBOLISM    OF    THE    CEREBRAL    VESSELS.  157 

find  that  the  patient  had  suddenly,  while  taking  his  beef-tea,  fallen  back 
unconscious,  and  had  remained  so  ever  since.  This  was  about  half  an 
hour  before  my  being  sent  for. 

His  pupils  were  widely  dilated,  and  his  cornese  when  touched  were  sen- 
sitive ;  his  legs  and  arms  were  extended.  His  temperature  was  not  high, 
and  his  breathing  had  not  changed  very  much  from  what  it  was  when  I 
saw  him  earlier  in  the  day. 

After  an  hour  and  a  half  he  made  some  movements  which  showed 
slight  voluntary  control,  and  vomited,  turning  his  head  -slightly  to  do  so. 
He  uttered  no  sounds  except  low  moans.  Towards  morning  his  breath- 
ing became  more  troubled,  and  he  rolled  in  the  bed. 

At  about  nine  o'clock  in  the  morning  of  the  next  day  he  seemed  to 
recognize  those  about  him,  and  made  signs  which  were  not  understood, 
when  he  knit  his  brows  and  seemed  perplexed.  He  refused  food,  but 
permitted  an  enema  of  beef-tea  to  be  injected,  but  this  was  not  retained. 
It  was  then  found  that  he  was  hemiplegic  on  the  right  side.  Later  in  the 
day  he  passed  his  urine  in  bed. 

l(jth  day.  Did  not  sleep  last  night.  The  temperature  104°  ;  pulse, 
130,  full  and  hard.  After  my  visit  this  morning  he  became  comatose. 
3  p.  M.,  died. 

Autopsy  20  hours  after  death. — Lungs:  right,  rather  more  pinkish 
than  normal ;  some  S]3ots  of  induration  at  base.  Left,  solidified  through- 
out most  of  its  substance  ;  when  cut,  bloody  serum  exuded.  Heart  some- 
what enlarged.  Mitral  valves  were  covered  by  stringy  clots.  The  right 
ventricle  contained  a  large  fresh  clot.  Kidneys :  right,  normal ;  left, 
somewhat  smaller  than  it  should  be ;  contained  a  small  cyst  beneath  the 
caj^sule.  Head  :  On  opening  the  cranial  cavity,  the  vessels  of  the  dura 
mater  were  filled  with  dark  blood.  The  longitudinal  sinus  contained  a 
quantity  of  thick,  clotted  blood,  which  was  almost  black.  The  left  hemi- 
sphere was  oedematous,  except  at  a  point  beneath  the  lateral  ventricle, 
where  there  was  a  circumscribed  patch  of  a  pinkish  hue,  which  seemed  to 
be  well  defined.  The  left  middle  cerebral  artery,  at  a  point  just  before  it 
gives  off*  its  branches,  was  found  to  be  swollen  and  hard,  and  when  cut 
open  a  small,  rather  firm  clot  was  found.  Behind  this  there  was  a  long, 
stringy  clot  of  more  recent  date.  About  the  vessel  the  brain  was  oedema- 
tous. Another  patch  of  red  softening  was  tbund  in  the  same  hemi- 
sphere somewhat  more  posteriorly.  No  other  large  arteries  were 
affected,  but  when  microscopically  examined,  I  found  considerable  occlu- 
sion of  many  small  capillaries,  and  great  disorganization  of  the  nerve 
element. 

I  have  seen  several  other  cases  of  this  kind  occurring  during  acute  dis- 
eases attended  b}^  a  hyperinosed  condition  of  the  blood. 

Causes. — Endocarditis  is,  above  all  other  causes  combined,  the  most 
important  and  common  in  the  production  of  embolism.  At  the  Patholo- 
gical Institute  of  Berlin^  there  were  300  cases  of  embolism  of  all  kinds 
associated  with  endocarditis  during  the  years  included  in  the  period  be- 
ginning 1868,  and  ending  1871.  Twenty  per  cent,  of  these  cases  were 
of  brain  embolism.  Of  a  large  number  of  cases  reported  in  the  London 
Pathological   Society's    Transactions,   nearly  all  of  them  were  of  this 

1  Edinburgh  Med.  Journ.,  July,  1873. 


158  OCCLUSION    OF    INTRACRANIAL     VESSELS. 

nature ;  and  out  of  fifteen  cases  I  have  seen,  twelve  were  connected 
with  disease  of  the  heart,  and  generally  with  deposits  upon  the  mitral 
valves. 

Croup,  the  puerperal  state,  phlebitis,  and  other  conditions  where  there 
is  any  tendency  to  the  formation  of  clots,  or  the  detachment  of  tissue 
which  finds  its  way  into  the  circulating  apparatus,  may  all  produce  em- 
bolism. 

Numerous  accidents  which  happen  through  carelessness,  or  perhaps 
unavoidable  injury  during  surgical  manipulation,  may,  by  the  introduc- 
tion of  a  blood-clot  or  foreign  substance  into  the  circulation,  produce  an 
occlusion  of  some  cerebral  or  other  vessel.  This  accident  has  occurred 
when  pressure  has  been  made  upon  large  aneurisms,  and  is  one  of  the 
arguments  against  the  intravenous  injection  of  substances  which  coagulate 
the  blood,  such  as  ergot,  persulphate  of  iron,  hair,  or  other  organic  sub- 
stances. 

Dr.  Barker^  has  given  two  cases  of  embolism  following  the  parturient 
state,  and  Thomas  has  seen  one  or  more  cases  of  this  kind. 

As  to  age,  I  have  found  that  more  young  people  have  had  cerebral 
embolism  than  persons  of  advanced  life.  An  examination  of  twelve 
cases  reported  by  different  observers  gives  the  relative  frequency  as  fol- 
lows : — 


lietween  10  and  20  years  . 

2 

Between  40  and  50  years  . 

2 

20    "  30      "     . 

4 

50    "    60    "      . 

1 

30    "  40      «     . 

3 

Of  these,  3  were  males,  and  9  were  females. 

Of  my  own  cases,  seven  were  between  twenty  and  thirty ;  five  between 
thirty  and  forty  ;  and  three  between  forty  and  sixty.  Eight  were  women, 
and  the  others  men.  It  seems,  therefore,  that  the  period  between  the 
twentieth  and  thirtieth  years  is  that  in  which  the  disease  is  most  common, 
and  that  women  are  most  subject  to  the  disease.  According  to  the  ob- 
servations of  medical  writers  in  general,  mitral  disease  is  more  often  an 
afiection  of  youth  or  early  life  than  of  advanced  years ;  so  it  seems  pro- 
bable that  people  who  have  not  reached  middle  life  should  be  more  sub- 
ject to  embolism. 

Diagnosis. — The  important  distinction  is  to  be  made  when  we  sus- 
pect the  case  to  be  one  of  cerebral  hemorrhage.  Next  in  order  come 
thrombosis,  cerebral  congestion,  meningeal  hemorrhage,  and  cerebral 
tumor. 

Gelpke'-  has  given  the  following  table,  on  one  side  of  which  are  detailed 
the  features  of  cerebral  embolism  ;  on  the  other,  those  of  cerebral  hemor- 
rhage : — 

CEREBRAL  EMBOLISM.  CEREBRAL  HEMORRHAGE. 

Youth  of  patient.  Advanced  age,  atheroma. 

Sudden  onset  without  prodromata.  Prodromata  generally  present. 

^  Puerperal  Diseases,  p.  270. 

"  Archiv  der  Heilkunde,  xvi.,  Aug.  1875,  p.  485. 


EMBOLISM    OF    THE    CEREBRAL     VESSELS.  159 

Previous   articular  rheumatism,   val-  Hypertrophy  of  left  ventricle. 

vular  sounds. 

Previous  disease,  which  might  lead 
to  formation  of  clots. 

The  Attach  The  Attach. 

Extensive  muscular  paralysis  ;  amne-  Symptoms  of  cerebral  pressure ;  ataxic 

sic  aphasia.  aphasia  ;  involvement  of  the  intelligence. 

Very   rapid ;   or  quite  imperceptible  Disappearance   of   the   residual    dis- 

disappearance  of  the  residual  disorder.  order  after  a  moderate  time. 

Eetention  of  early  mental  power.  Keaction  stage. 

Janeway^  relates  an  admirable  case  to  illustrate  the  obstacles  some- 
times encountered  in  making  a  diagnosis.  As  it  will  be  seen  in  his  case, 
there  were  many  circumstances  of  a  puzzling  character  which  made  the 
diagnosis  exceedingly  difficult. 

A  young  woman,  while  at  work,  fell  to  the  floor  unconscious,  in  what 
appeared  to  be  a  "  fainting  fit."  There  were  some  convulsive  movements 
limited  to  the  left  side  of  the  body.  When  admitted  to  Bellevue  Hos- 
pital on  the  following  day,  there  were  irregular  contraction  of  the  pupils, 
coma,  and  high  temperature.  A  loud  systolic  murmur  was  heard  all  over 
the  chest.  She  remained  unconscious  for  two  days,  and  on  the  third 
day  died.  Her  breathing  previous  to  death  was  stertorous,  her  limbs 
flaccid,  and  reflex  action  diminished.  The  pupils  were  dilated.  Her 
urine  contained  a  small  amount  of  albumen,  but  not  enough,  in  the  ab- 
sence of  oedema  and  other  symptoms,  to  suggest  nephritic  trouble ;  be- 
sides, the  quantity  of  urine  passed  was  sufficient.  The  question  of  throm- 
bosis was  excluded  by  the  absence  of  premonitory  symptoms.  Congestive 
chill  was  suggested  by  the  paralysis  and  meningeal  hemorrhage,  but  ex- 
cluded when  the  absence  of  rigidity  was  taken  into  account.  Janeway 
considered  the  lesion  to  be  hemorrhage,  and  I  will  give  his  own  descrip- 
tion of  the  autopsy  and  its  result. 

"The  j)os^?norfe7?^  examination  revealed  the  following:  Skull,  normal. 
Brain  and  membranes  :  On  opening  the  dura  mater  on  the  right  side, 
a  clot  of  blood,  a  little  over  half  an  inch  thick,  three  inches  long,  and 
two  inches  wide,  escajDed  from  the  arachnoid  sac.  This  clot  was  in  the 
main,  black,  moderately  soft,  but  provided  with  a  buffy  coat  at  one  por- 
tion. It  had  produced  a  corresponding  depression  of  the  brain,  over 
which  it  was  situated,  and  in  its  centre  was  an  oj)ening  about  an  inch 
long  and  a  half  inch  wide,  leading  fr'om  a  recent  excavation  in  the  middle 
lobe  of  the  brain,  through  the  torn  pia  mater  and  so-called  arachnoid,  into 
the  sac  of  the  latter.  This  excavation  reached  from  the  convex  surface 
nearly  to  the  corpus  and  optic  thalamus  at  posterior  extremity.  The 
opening  was  situated  a  little  nearer  to  the  longitudinal  fissure  than  would 
correspond  to  the  middle  of  the  convex  surface.  The  excavation  was 
about  two  inches  wide  and  contained  clotted  blood,  of  which  some  had 
escaped  in  removing  brain.  The  brain- tissue  surrouniling  this  was  soft, 
slightly  blood-stained,  and  where  it  formed  the  boundaries  of  the  space, 

^  Am.  Psychological  Journal,  ^N'ov.  1876. 


160  OCCLUSION    OF    INTRACRANIAL    VESSELS. 

numerous  small  torn  vessels.  The  brain-tissue  of  the  posterior  lobe,  espe- 
cially on  its  outer  surface,  was  softer  than  natural.  The  posterior  ex- 
tremity of  the  optic  thalamus  of  the  right  side,  over  a  small  area,  pre- 
sented an  ecchymotic  softened  state. 

"  In  the  clotted  blood  and  disintegrated  brain-tissue  found  at  the  mouth 
of  the  excavation,  a  small  branch  of  the  posterior  cerebral  was  found  torn 
across,  presenting  a  widened  extremity  at  the  point  of  rupture,  surrounded 
by  thickened  and  firm  tissue,  and  in  the  interior  of  this  a  firm  reddish- 
gray  clot,  uniform  in  its  structure  and  of  older  date  than  any  others.  I 
failed  on  careful  examination  to  find  the  other  extremity  of  the  torn  ves- 
sel, but  from  the  condition  of  the  portion  found  doubt  not  that  it  would 
have  proved  of  similar  shape  to  the  other,  and  that  together  they  would 
have  constituted  a  cylindrical  dilatation  of  this  artery. 

"  The  left  (opposite)  hemisphere  showed  the  convolutions  flattened  and  so 
closely  pressed  together  laterally  as  to  nearly  obliterate  the  appearance 
of  sulci.  The  arach  noid  was  dry,  and  there  was  no  sub-arachnoid  fluid 
present.  The  brain  on  this  side  appeared  antemic,  and  on  cutting  the 
dura  mater,  pressed  out. 

"  The  lateral  ventricles  were  of  normal  appearance.  The  anterior  lobe 
of  right  side  was  normal.  Pons,  cerebellum,  etc.,  were  normal.  The 
arteries  at  the  base  were  carefully  examined,  being  followed  to  their 
smaller  ramifications  without  finding  any  emboli. 

"  The  lungs  were  slightly  edematous. 

"  Heart :  The  left  ventricle  was  slightly  hypertrophied.  On  the  auri- 
cular aspect  of  the  mitral  valve,  and  on  the  ventricular  of  the  aortic, 
condylomatous  excrescences  were  present,  narrowing  both  orifices ;  but 
the  largest  mass  passed  obliquely  across  the  heart  from  the  leaf  of  aortic 
valves  nearest  the  septum  to  the  anterior  leaf  of  mitral  valves,  and  above 
this,  between  it  and  the  other  leaflet  of  aortic  valves,  a  slight  dilatation 
of  the  heart-wall  existed. 

"  Small  infarctions  were  present  in  the  spleen  and  the  kidney,  and  the 
latter  showed  at  some  points  interstitial  nephritis,  around  glomeruli,  with 
atrophy  of  these  ;  but  the  disease  was  not  advanced.  The  mesentery  pre- 
sented two  small  aneurismal  dilatations  of  little  arteries,  and  at  these 
points  emboli  were  present :  one  was  of  the  size  of  the  head  of  a  pin  ;  the 
other,  of  a  pea. 

"  In  this  case  it  seems  exceedingly  probable  that  the  primary  lesion  of 
the  artery,  which  finally  ruptured,  was  embolism,  and  that  this  obstruction 
caused,  secondarily,  a  dilatation  of  the  artery  at  this  point,  and  that, 
owing  to  the  heat,'  such  an  obstruction  of  the  circulation  in  the  brain  oc- 
curred as  to  cause  the  rupture  of  the  vessel  described.  This  is  rendered 
still  more  probable  by  finding  two  small  arteries  in  the  mesentery  with 
aneurismal  dilatation,  and  containing  emboli. 

"A  point  of  interest  in  this  case  is  the  absence  of  serious  symptoms  of 
cardiac  disease,  though  there  was  so  marked  a  lesion.  It  did  not  seem 
as  if  any  regurgitation  had  occurred  at  the  aortic  orifice,  simply  obstruc- 
tion. The  left  ventricle  contained  such  a  firmly  adherent  clot  that  the 
hydrostatic  test  was  of  no  avail. 

^  The  weather  was  excessivdy  warm  at  this  time,  and  the  patient  was  at  first  sup- 
posed by  those  around  her  to  be  suffering  from  the  effects  of  the  heat. 


EMBOLISM    OF    THE    CEREBRAL    VESSELS.  IGl 

"  It  also  furnishes  anotlier  to  the  already  long  list  of  cases  in  which  a 
heart-murmur  is  heard — sudden  paralysis  occurs — the  patient  moderately 
young,  and  yet  the  lesion  is  hemorrhage,  and  not  embolism.  I  have  met 
with  several  of  these  exceptions." 

From  thrombosis  there  will  be  no  difficulty  in  making  a  diagnosis  when 
we  remember  the  slow  origin  of  the  former.  The  "  apoplectic  form  "  of 
cerebral  congestion  sometimes  resembles  the  condition  presented  by  the 
patient ;  howcA'er,  the  former  history,  the  suffused  face,  contracted  pupils, 
and  rapid  subsidence  of  symptoms,  will  put  us  on  our  guard. 

Morbid  Anatomy  and  Pathology. — Burrowes  and  Kirkes  were 
the  first  English  writers  and  Virchow  the  earliest  Continental  writer  to 
describe  these  conditions.  Prevost  and  Cotard  have  since  related  inter- 
esting experiments.  They  injected  tobacco  seed  into  the  carotids  of  dogs, 
and  afterwards  watched  the  changes  that  followed.  One  of  these  dogs 
was  killed  thirty-nine  days  after  the  seed  had  been  introduced,  when  they 
found  the  middle  cerebral  artery  obstructed,  and  induration  about  the 
fissure  of  Sylvius. 

The  pathological  processes  which  follow  such  mechanical  obstruction 
have  been  sufficiently  noticed  in  a  preceding  article,  so  it  will  be  enough 
to  call  attention  to  the  fact  that  the  consequence  of  such  an  accident  will 
be  softening  of  the  parts  deprived  of  their  nourishment,  unless  the  collat- 
eral circulation  be  established  at  an  early  date,  or  the  embolon  is  broken 
down  and  removed,  which  is  a  very  unlikely  circumstance. 

Kirkes  ^  calls  attention  to  the  distribution  of  emboli  in  the  following 
words :  "  The  parts  of  the  vascular  system,  within  which  these  transmit- 
ted masses  of  fibrine  may  be  found,  will  of  course  depend  in  a  great 
measure  upon  whether  they  proceed  from  the  right  or  left  side  of  the 
heart.  Then,  if  they  have  been  detached  from  either  the  aortic  or  mitral 
valves,  they  will  pass  into  the  blood  propelled  by  the  left  ventricle  into 
the  aorta  and  its  subdivisions,  and  may  be  arrested  in  any  of  the  systemic 
arteries  or  their  modifications  in  the  various  organs,  especially  those  which, 
like  the  brain,  spleen,  and  kidneys,  receive  large  supplies  of  blood  di- 
rectly from  the  left  side  of  the  heart.  If,  on  the  other  hand,  the  fibrinous 
masses  are  derived  from  the  pulmonary  artery  and  its  subdivisions  within, 
the  lungs  will  necessarily  become  the  primary  if  not  the  exclusive  seat  of 
their  subsequent  deposition." 

In  regard  to  the  side  of  the  brain  where  the  deposit  occurs,  I  think  we 
may  say  that  the  left  side  and  the  middle  cerebral  artery  are  the  most 
common  site,  though  many  cases  reported  by  Shaw,  Glynne,  Murchison, 
and  others  prove  that  the  right  artery  may  be  affected  as  well. 

An  interesting  example,  which  is  almost  unique,  is  the  following  case  of 
embolism  of  the  right  posterior  cerebral  artery.  The  history  was  read  by 
Broadbent  before  the  London  Clinical  Society  : — ' 

"  The  patient,  a  young  man  aged  19,  had  suffered  three  years  pre- 

1  Eoyal  Med.  Chir.  Trans.,  vol.  xxxv.,  p.  281,  1852. 
^Abstracted  from   Lancet,  Monthly  Abstract,  April,  1876,  p.  576. 
11 


162  OCCLUSIOX    OF    INTRACRANIAL    VESSELS. 

viously  from  acute  rheumatism.     Ten  days  before  his  admission,  he  sud- 
denly became  blind,  and  had  great  pain  in  the  head.     Five  days  later, 
vision  having  returned,  he  lost  the  use  of  his  left  limbs,  while  the  right 
arm  and  leg  were  continually  in  motion;  and,  unless  restrained,  he  rolled 
over  and  over  towards  the  left,  falling  out  of  bed  and  bruising  himself  se- 
verely.    The  left  hemiplegia  and  uncontrollable  movements  of  the  right 
limbs  continued  when  he  was  admitted  ;  the  hemiplegia  not  being  abso- 
lute, but  accompanied  by  slight  rigidity  and  very  considerable  impair- 
ment of  sensation.     The  patient  took  no  notice  of  persons  or  objects,  but 
answered  questions,  and  put  out  the  tongue  on  being  urged.     His  pulse 
was  variable,  120   to    160   or  more.     Temperature  in  the  right  axilla, 
99.2°;  in  the  left,  100.6°.     A  loud  mitral  systolic  murmur  was  present. 
The  bowels  were  confined,  and,  when  opened,  the  feces  and  urine  were 
passed  in  bed.     A  dose  of  three  grains  of  calomel  was  given,  and  two 
grains  of  carbonate  of  ammonia,  with  two  drachms  of  infusion  of  digitalis 
every  two  hours.     Chloral  also  was  given  at  night.     He  was  ordered  a 
diet  of  milk  and  beef-tea,  with  four  ounces  of  brandy.     There  was  gra- 
dual improvement ;  and  three  days  after  his  admission,  an  ophthalmosco- 
pic observation,  previously  attempted  in  vain,  was  obtained,  and  the  disks 
were  found  to  present  the  appearances  of  marked  ischsemia.     The  pulse 
was  now  108,  soft,  short,  and  strikingly  dicrotous.     A  day  later  the  pulse 
was  88,  and  more  full.    The  temperature  was  still  nearly  a  degree  higher 
in  the  left  (100°)  than  in  the  right  (92.2°)  axilla.     Slight  paralysis  of 
the  left  external  rectus  of  the  eye  was  observed.     At  the  end  of  a  fort- 
night's stay   in   hospital,   the  right  limbs   were    quiet,   and  there   was 
considerable  return  of  power  and  sensation  in  the  left  side.     His  speech 
was  rather  slow,  but  there  was  no  obvious  impairment  of  the  intellect. 
Notwithstanding  this,  however,  he  not  only  passed  his  feces  in  bed,  but 
threw  them  about  and  bedaubed  himself  and  the  bedclothes  without  any 
regard  to  decency.    The  optic  ischtemia  was  marked,  but  vision  was  good. 
The  temperature"  of  the  right  axilla  was  99.3°;  of  the  left,  10U°.     At  the 
end  of  three  weeks  he  passed  his  excretions  naturally.     After  five  weeks 
he  was  up  and  about,  eating  well ;  but  pale,  and  still  complaining  a  little 
of  headache.     Impairment  of  power  and  of  sensation  in  the  left  limbs 
was  still  perceptible.     The  optic  neuritis  was  subsiding.     Distant  vision 
was  good,  but  small  print  was  not  easily  read.     A  systolic  mitral  mumur 
was  heard.     The  temperature  was  still  never  below  99°;  usually  100° ;  it 
was  now  equal  on  the  two  sides.     But  for  this  elevation  of  temperature, 
the  patient  would  have  been  allowed  to  leave  the  hospital.     Soon  after- 
wards, however,  there  were  symptoms  of  splenic  embolism,  and  later  of 
ulcerative  endocarditis;  and  he  died  from  this  four  months  after  admis- 
sion.    On  post-mortem  examination,  with  ulcerative  endocarditis  and  nu- 
merous recent  embolisms,  there  was  found  softening  of  the  occipital  lobe 
of  the  right  hemisphere  from  the  posterior  cornu  of  the  ventricle  down- 
wards, and  the  branch  of  the  post-cerebral  artery  entering  the  calcarine 
fissure  was  occluded  and  lost  in  adhesions.     It  was  considered  probable 
by  Dr.  Broadbent  that  originally  the  posterior  cerebral  artery  itself  had 
been  blocked  up,  and  not  only  this  branch.    The  interesting  points  in  the 
case,  on  which  comments  were  made,  were  the  temporary  blindness,  the 
agitation  of  the  right  limbs,  and  rolling  tendency,  the  usual  association  of 
loss  of  sensation,  and  of  double  optic  ischiemia  with  embolism  of  a  cere- 
bral artery,  and  the  remarkable  indifterence  to  decency  persisting  when 
the  intellect  was  apparently  good." 


EMBOLISM    OF    THE    CEREBRAL    VESSELS.  163 

Fat  globules  may  sometimes  plug  up  the  small  capillaries,  producing 
wide  areas  of  softeuing. 

The  morbid  appearances  indicative  of  cerebral  softening  are  of  interest 
and  worthy  of  the  closest  study,  not  only  because  the  brain  is  the  point 
which  suffers  the  most  seriously,  but  because  generally  the  heart,  spleen, 
lungs,  blood-vessels,  and  other  organs  may  be  involved  as  well.  On  the 
valves  of  the  heart,  either  mitral  or  aortic,  may  be  found  excrescences, 
induration  or  recent  clots,  and  the  arteries  themselves  may  exhibit  patches 
of  atheroma.  In  the  brain  we  will  probably  find  one  or  more  of  the  ar- 
teries I  have  spoken  of  to  be  swollen,  hard,  and  filled  by  one  of  these 
little  masses  of  fibrine.  They  have  been  coinpared  to  grains  of  wheat, 
and  resemble  them  very  closely.  Generally  the  embolon  is  separated 
from  a  second  plug  which  has  followed  clotting  of  the  arrested  blood. 
Emboli  are  never  attached  to  the  walls  of  the  vessels. 

Several  arteries  may,  perhaps,  be  found  obstructed  in  the  same  way. 
"  Sometimes  all  on  one  side  ;  at  other  times  some  arteries  of  one  side  of 
the  brain,  and  some  of  the  other,"^  so  says  Fox. 

Softened  masses  are  generally  found  on  examination,  and  are  usually 
the  cause  of  death.  The  parts  behind  the  occlusion  are  subjected  to  the 
full  force  of  blood  which  is  arrested,  and  not  sent  to  the  parts  it  should 
supply,  and  local  hypereemia  is  a  result.  The  resulting  softening  is 
generally  confined  to  the  left  hemisphere  at  its  base,  for  reasons 
I  have  before  stated,  and  the  frontal  convolutions,  corpus  striatum, 
and  adjacent  parts  are  found  to  be  either  red  or  yellow,  softened  or  in- 
durated 

OEdema  of  the  brain  is  not  an  uncommon  appearance,  such  oedema 
being  seen  in  the  parts  deprived  of  blood.  The  perivascular  spaces  being 
enlarged,  it  is  but  natural  that  their  fluid  should  rush  in  to  fill  up  the  in- 
creased space  left  by  the  bloodless,  arteries. 

Prognosis. — The  outlook  for  the  patient  is  generally  a  very  gloomy 
one  if  the  accident  be  at  all  grave,  and  the  artery  be  one  of  importance. 
The  severity  of  the  symptoms,  the  existence  of  emboli  in  other  organs, 
the  element  of  severe  pain,  high  temperature,  and  gradual  development 
of  symptoms  indicative  of  softening  are  of  unfavorable  import,  and  give 
affairs  a  very  dark  look ;  therefore  it  is  never  well  to  make  too  hasty  a 
prognosis. 

Treatment. — Rest,  abstinence  from  stimulants,  and  agents  which 
will  diminish  the  arterial  tension  are  the  only  remedial  means  to  adopt 
besides  the  ordinary  indications  which  appeal  to  the  common  sense  and 
discretion  of  the  medical  man.  Afterwards,  resulting  conditions,  such  as 
paralysis  or  softening,  are  to  be  treated. 

1  Op.  cit.,  p.  32. 


164         DISEASES    OF    THE   CEREl'.RUM   AND   CEREBELLUM. 


CHAPTEK    y. 

DISEASES  OF  THE  CEREBRUM  and  CEREBELLUM  (Continued). 
CEREBRAL  SOFTENING. 

Synonyms. — Reuipllissement  (rouge,  blauc,  jaune).  Eucephalitis 
aigue,  chronique  (Fr).  Mollities  cerebri,  Encephalitis,  Softening  of  the 
Brain  (chronic,  acute).  Inflammation  of  the  Brain. 

Definition. — A  disease  of  the  brain  attended  by  destruction  of  ner- 
vous substance,  and  either  of  an  acute  inflammatory  nature,  with  puru- 
lent formation  ;  or  of  a  chronic  non-inflammatory  character,  with  less 
rapid  disorganization  of  nerve-tissue. 

So  much  confusion  has  arisen  from  an  incorrect  appreciation  of  the 
morbid  anatomy  and  its  connection  with  pathology,  that  it  is  a  difficult 
matter  to  attempt  there  conciliation  of  the  many  widely  differing  views 
of  the  legion  of  writers.  "  Inflammation  of  the  brain  "  is  the  term  which 
has  led  to  all  this  confusion ;  and  I  have  been  bold  enough  to  base  my 
classification  rather  upon  the  character  of  tissue-changes  than  upon  the 
arbitrary  law  that  softening  of  the  brain  is  the  only  result  of  in- 
flammation. Sclerosis,  as  we  know,  is  undoubtedly  the  result  of  a  low 
grade  of  inflammation,  but  in  this  case  the  tissue-changes  are  quite 
diff'erent. 

Considering  that  the  word  "  softening"  means  a  mollification,  and  that 
it  may  result  not  only  from  purulent  inflammation,  but  from  low  nutritive 
changes,  I  shall  divide  the  subject  as  follows  : — 


Diffused  Cerebritis. 
Meningo-Cerebritis. 


1.  Acute  Softening,  \ 
(Inflammatory),              (     Purulent  Cerebritis 

2.  Chronic  Softening,  f      Primary  Softening. 
(Non-Inflammatory),      I      Secondary  Softening. 

1.  Under  the  first  head  we  may  place  the  variety  described  by  Elam,' 
which  is  a  quite  rare  affection  in  its  uncomplicated  form,  that  is,  when  it 
involves  the  brain  substance  en  masse;  and  meningo-cerebritis,  which  is 
by  far  more  common.  In  a  third  variety  the  acute  disease  is  character- 
ized by  purulent  collections,  and  perhaps  by  the  ultimate  formation  of 
abscesses. 

2.  Chronic  softening  in  its  primary  form  we  will  consider  to  be  de- 
pendent upon  general  disease,  intellectual  prostration,  and  like  causes  ; 

^  Cerebria,  and  other  Diseases  of  the  Brain,  London,  1872.  • 


ACUTE    SOFTENING.  165 

while  "  secondary  softening  "  may  be  used  to  express  the  form  which 
follows  vascular  lesions,  such  as  embolism,  thrombosis,  or  cerebral  hemor- 
rhage. 

ACUTE   SOFTENING. 

In  the  first  form  it  may  be  either  cortical,  diiFused,  or  combined  with 
meningitis. 

Symptoms. — Cerebritis  of  either  kind  is  preceded  in  nearly  every 
instance  by  symptoms  of  functional  disorder,  such  as  cerebral  congestion 
or  cerebral  ansemia,  but  these  are  not  sufficient  in  themselves  to  arouse  the 
suspicion  of  the  observer  as  to  the  serious  character  of  the  disease  which 
is  to  follow.  The  later  prodromata  of  cerebritis,  however,  cannot  be  mis- 
taken, and  finally  the  developed  disease  presents  most  pronounced  symp- 
toms, which,  if  they  do  not  always  enable  us  to  locate  the  brain  lesion,  are 
sufiicient  to  assure  us  that  some  violent  inflammatory  process  is  under 
way  in  the  cerebral  mass.  The  patient  may  for  some  months  suffer 
greatly  from  headache  of  a  diffused  character,  accompanied  by  burning 
sensations,  and  a  sense  of  pressure  behind  the  eyeballs.  These  headaches 
are  quite  intense,  and  are  aggravated  by  exposure  to  heat,  concentration 
of  the  mental  powers,  and  alcoholic  indulgence.  His  memory  becomes 
gradually  enfeebled,  so  that  at  first  dates  and  names  are  forgotten,  and 
afterwards  faces,  locations,  and  even  information  which  may  have  been 
imparted  to  him  a  short  time  pi-eviously.  Some  slight  clum-iness  of 
speech  may  be  indicative  of  the  near  approach  of  grave  symptoms,  but 
this  clumsiness  is  not  aphasic  till  later.  Irritability  of  temper,  restless- 
ness, and  incapacity  for  mental  application  are  attendant  evidences  of  the 
smouldering  fire  which  afterwards  is  to  make  itself  known  by  still  more 
decided  symptoms,.  Among  these  may  be  enumerated  nystagmus,  stra- 
bismus, diplopia,  and  optic  neuritis,  as  ocular  troubles  ;  contractures  of 
the  limbs,  tremors  of  individual  muscles,  or  groups  of  muscles,  a  twitching 
of  the  limb^,  or  other  motor  troubles,  and  hypersesthesia,  followed  by  anaes- 
thesia, and  other  disorders  of  sensation ;  these  last  sometimes  being  pe- 
culiarly prominent.  Next  we  find  that  there  may  be  an  apoplectic 
attack  or  convulsions  of  an  epileptiform  character,  which  mark  the  violent 
stages  of  the  disease.  Should  there  be,  as  a  result  of  the  morbid  process, 
cerebral  hemorrhage,  it  will  be  found  that  the  paralyzed  limbs  become 
markedly  contracted,  and  that  rigidity  is  a  striking  feature,  as  the  result 
of  descending  degeneration.  According  to  Jaccoud,  the  contractures  may 
be  bilateral,  though  the  rule  is  the  other  way,  the  limbs  of  but  one  side 
being  rigidly  flexed.^  He  has  seen  one  case  where  the  left  arm  and  leg 
were  the  seat  of  contractures,  and  where  the  face  was  contracted  and 
strongly  drawn  towards  the  left  side,  suggesting  a  right  facial  palsy,  but 
the  appreciable  rigidity  of  the  facial  muscles  of  the  left  side  left  no  doubt 
as  to  the  origin  of  the  deviation.     The  paralyzed  members  are  generally 

1  Traite  de  Path.  Interne,  vol.  i.,  Art.  Enceph.  aigue. 


]6G         DISEASES   OF    THE    CEREBRI'M     AXD    CEREBELLUM. 

those  that  are  the  seat  of  convulsive  movements  in  the  first  place.     The 
convulsions  may  be  general,  and  assume  an  epileptiform  character,  and 
may  be  accompanied  by  vomiting.     The  patient's  mental  condition  mean- 
while undergoes  a  great  change.     Delusions,  which  somewhat  resemble 
those  of  general  paralysis  of  the  insane,  are  present ;  the  exaltation  deli- 
rante  of  the  French,  which  is  by  some  considered  to  be  an  early  symp- 
tom.    This  has  not  been  my  experience,  and  I  am  convinced  that  in  the 
cases  where  it  has  been  noticed  as  an  early  expression  of  the  affection,  the 
disease  was  probably  general  paralysis,  and  not  cerebritis.     The  real  de- 
partures from  mental  integrity  are  expressed  in  a  want  of  decision  and  a 
restlessness  which  is  shown  in  the  impaired  fixedness  of  purpose.    The  pa- 
tient repeats  himself  in  conversation,  and  forgets  that  he  has  made  the 
same  statement  but  a  few  minutes  previously.     Memory  is  ultimately 
abolished,  and  finally  dementia  remains,  which,  should  the  patient  live  for 
some  time,  is  expressed  by  all  the  other  signs,  drivelling  of  saliva,  inane 
smile,  hebetude,  and  total  imbecility,  while  there  may  be  aphasia  of  the 
amnesic  or  ataxic  variety.     The  muscles  concerned  in  articulation  and 
deglutition  are  involved,  and  the  patient  may  narrowly  escape  being 
choked  by  the  masses  of  food  which  "  go  down  the  wrong  way"  or  accumu- 
late in  his  mouth.     Constipation  and  retention  of  urine  are  not  uncom- 
mon accompaniments,  and  the  urine  is  charged  with  urates,  is  dark-colored, 
and  rapidly  undergoes  decomposition.     The  temperature  and  pulse  are 
both  changed,  the  latter  becoming  accelerated  and  irregular,  and  the  heart- 
sounds  sharp  and  "  precipitative."     A  tremulous  character  of  the  pulse 
has  been  noticed  by  several  observers.     The  temperature  may  rise  to  110^ 
F.,  and  generally  attains  its  highest  point  at  the  end  of  the  first  four  days. 
Coma  precedes  a  fatal  ending  in  the  acute  form  at  the  end  of  a  few  days, 
and  death  occurs  generally  after  seven  or  eight  days  by  asphyxia.    Should 
the  patient  survive,  there  is  a  remission  of  the  symptoms,  and  the  forma- 
tion generally  of  an  abscess.    Cerebritis  does  not  always  begin  in  the  same 
way,  and,  as  I  have  already  stated,  is  not  invariably  symptomatized  by  all 
the  forms  of  disordered  function  I  have  enumerated.     There  may  be  no 
premonitory  symptoms  .should  the  disease  follow  otitis  or  injury,  but  in 
the  insidious  form,  which  has  been  so  admirably  described  by  Elam  and 
Eeynolds,  the  appearance  of  prodromata  is  gradual  and  progressive.     In 
certain  cases  the  paralysis  is  an  early  symptom,  in  others  the  defects  of 
articulation  and  deglutition  are  more  prominent ;  in  other  cases  psychical 
disturbances  are  decided,  while  in  still  others  coma  or  convulsions  are  the 
striking  features.    The  predominance  of  these  different  symptoms  depends 
very  much  upon  the  region  which  suffers  the  most  from  the  violence  of 
inflammatory  action.     It  must  be  borne  in  mind  that  the  disorder  is,  as  a 
rule,  attended  from  the  fir.st  by  febrile  disturbances,  and  that  all  the  .symp- 
toms are  those  indicative  of  a   hyperaesthetic  state  of  the  cerebrum. 
Should  the  patient  survive  the  immediate  violence  of  the  attack,  he  may 
recover  to  some  degree.    The  temperature  and  pulse  are  lowered  ;  the  ac- 
tive evidence  of  the  central  disease  subsides,  but  it  is  not  common  for  any 
amelioration  of  the  paralysis  to  take  place.     The  headache  may  become 


ACUTE    SOFTENING.  167 

more  localized  and  less  intense,  or  may  subside  altogether,  and  it  may 
only  reappear  when  the  patient  is  fatigued.  He  may  remain  in  this  con- 
dition for  several  years.  In  one  case  that  came  under  my  observation  I 
accidentally  found  a  large  abscess  about  the  size  of  a  horse  chestnut  in  the 
white  matter  of  the  anterior  lobe  of  the  right  hemisphere.  The  individual 
had  died  of  phthisis,  and  during  life  complained  of  no  symptoms  which 
would  direct  suspicion  to  the  brain  lesion.  He  had  had  a  febrile  attack 
six  years  before,  which  was  probably  the  time  at  which  the  abscess  was 
formed.  In  many  cases  cerebral  abscess  follows  disease  of  the  temporal 
bone,  and  in  the  majority  of  instances  it  is  not  essentially  necessary  that 
there  should  be  complicating  general  meningitis,  though  such  is  often  the 
case. 

Causes. — Exposure  to  the  sun's  rays,  alcoholism,  inflammatory  dis- 
ease of  the  bones  of  the  head  or  face,  meningitis,  brain  tumors,  trauma- 
tism, and  syphilis,  as  well  as  several  of  the  zymotic  fevers  and  rheuma- 
tism, are  all  predisposing  and  exciting  causes  of  cerebritis.  The  simple 
form  may  be  idiopathic,  but  that  which  results  in  the  production  of 
abscesses  is  more  often  due  to'  traumatism,  caries  of  adjacent  bones,  or 
syphilis.  Jaccoud  has  found  that  the  proportion  of  patients  in  regard  to 
sex  was  in  favor  of  the  males,  nine  men  being  affected  to  every  four 
women,  and  that  the  disease  was  developed  between  puberty  and  the  forty- 
fifth  year.  Cerebral  abscess  or  traumatic  cerebritis  may  be  produced,  of 
course,  at  any  age  by  injuries  or  the  extension  of  other  diseases.  I  have 
seen  one  case  in  which  cerebritis  followed  otitis  in  a  child  ten  years  old. 
Lead  poisoning  should  not  be  forgotten  as  a  rare  cause. 

Morbid  Anatomy  and  Pathology. — Cerebritis  may  either  in- 
volve the  cortex  cerebri  or  some  central  parts,  such  as  the  corpora  striata 
or  optic  thalami,  or  more  rarely  may  affect  the  entire  brain,  but  it  pre- 
fers the  gray  matter,  which  is  so  richly  supplied  by  blood  vessels.  The 
brain  may  be  found  to  be  the  seat  of  many  softened  parts,  and  collections 
of  pus,  serous  exudation  from  the  vessels  infiltrating  the  surrounding 
brain-tissue,  or  there  may  be  ruptured  vessels,  and  an  escape  of  their  con- 
tents. The  brain-tissue  may  be  stained  by  the  hematin,  and  occasionally 
presents  the  appearance  of  simple  non-inflammatory  softening.  The 
microscope  enables  us  to  see  a  multiplicity  of  changes — granular  degene- 
ration, leucocytes,  broken-down  nerve-elements,  rarely  neuroglia-thicken- 
iug,  and  still  more  rarely  amyloid  bodies.  I  know  of  no  more  interest- 
ing field  for  the  study  of  morbid  microscopical  anatomy  than  a  brain  of 
this  kind,  for  nearly  every  appearance  or  grade  of  diseased  structure  may 
be  found.  The  vascular  lesions  are  capillary  hemorrhage,  miliary  aneu- 
rism, etc.  Suppuration  takes  place  in  several  ways.  The  brain-substance 
may  be  generally  infiltrated,  so  that  it  presents  a  yellow  color  through- 
out its  extent,  or  there  may  be  a  localized  infiltration  or  an  encysted  col- 
lection of  pus.  About  the  latter  will  be  found  a  sclerosis  of  the  brain- 
tissue,  and  about  this  a  serous  infiltration.  Jaccoud  has  found  that 
abscesses  are  more  often  to  be  observed  in  the  white  substance,  in  which 


168        DISEASES   OF   THE   CEREBRUM     AND    CEREBELLUM. 

conclusion  he  is  supported  by  the  observations  of  many  writers.  Lebert,' 
in  fifty-eight  cases,  found  the  abscess  to  be  located  twenty-three  times  in 
the  left  hemisphere,  eighteen  in  the  right,  twice  in  the  corpora  striata, 
twelve  times  in  the  cerebellum,  twice  in  the  pituitary  body,  and  once  in 
the  spinal  cord.  I  have  already  presented  cases  which  will  enable  the 
reader  to  appreciate  the  origin  and  size  of  such  collections  of  purulent 
matter,  and  the  evidences  of  diseased  bone,  fracture,  etc.,  that  are  to  be 
discerned  in  cases  of  traumatism  or  disease.  In  certain  pysemic  condi- 
tions, such  as  erysipelas,  abscesses  may  be  found  in  other  parts  of  the 
body  as  well,  notably  in  the  liver  and  lungs.  In  rare  forms  a  rapid  ne- 
crobiosis or  "  death "  of  tissues  takes  place,  which  is  almost  analogous 
with  gangrene  in  other  parts  of  the  body,  and  large  masses  of  brain- 
tissue  are  destroyed  very  rapidly. 

Of  fifteen  cases  of  cerebral  softening  of  acute  form,  CalmeiP  found  in 
one  fibrine  in  the  sinuses  of  the  dura  mater ;  in  one,  this  membrane  was 
bathed  in  purulent  liquid,  and  it  was  also  perforated  at  one  point;  in  five 
there  were  recent  spots  of  encephalitis  on  the  right  and  left  sides,  in  six 
on  the  left  only,  in  three  on  the  right  only ;  in  three  there  were  cellular 
cicatrices  in  the  right  lobe  of  the  brain,  in  one  in  the  left  lobe ;  in  two 
the  right  hemisphere  of  the  cerebellum  was  the  seat  of  an  acute  inflam- 
matory spot;  in  four  the  principal  recent  inflammatory  spots  were  still 
in  a  state  of  red  hepatization ;  in  seven  they  were  in  a  state  of  softening, 
with  disintegration  of  the  nervous  substance;  in  four  they  were  in  a  state 
of  disintegration  of  the  nervous  substance,  with  a  mixtui-e  of  a  liquid 
that  resembled  pus ;  in  four  the  spots  of  acute  local  encephalitis  without 
clot  were  studied  microscopically.  Of  these,  in  one  they  were  still  in  the 
state  of  red  hepatization  ;  the  diseased  regions  were  reddened  by  the 
widening  of  the  capillaries,  and  by  the  presence  of  extravasated  globules 
of  blood  ;  the  cerebral  fibres  were  not  yet  disintegrated ;  already  small 
granular  cells  had  begun  to  be  formed  in  the  inflamed  parts.  In  three 
the  nervous  substance  of  the  diseased  seats  was  disintegrated,  and  more 
or  less  reduced  to  fragments ;  it  was  soaked  in  plasma,  mixed  with  a  con- 
siderable number  of  great  cells  collected  together,  and  molecular  granules ; 
sometimes  in  the  preparation  there  were  seen  rare  globules  of  pus  scat- 
tered. The  vessels  and  their  principal  branches  were  constantly  very 
apparent. 

Diagnosis. — Cerebral  hemorrhage,  meningitis,  cerebral  tumor,  embo- 
lism, and  thrombosis  are  all  conditions  from  which  it  is  proper  we  should 
distinguish  acute  cerebritis  and  cerebral  abscess. 

Some  of  the  symptoms  of  general  paralysis  of  the  insane  may  possibly 
mislead  the  observer.  From  cerebral  hemorrhage  we  are  to  distinguish 
cerebritis  by  the  rapid  amendment  of  symptoms  in  the  former,  while  in 
the  latter  there  is  progressive  evidence  of  advancing  structural  changes. 
Fever  is  not  connected  with  cerebral  hemorrhage,  unless  there  be  second- 

'Virchow's  Archiv,  x.  1866. 
*  Quoted  by  Fox. 


ACUTE    SOFTENING.  169 

ary  inflammation  of  the  brain-substance.  The  headache  is  not  sugges- 
tive of  cerebral  hemorrhage,  nor  is  the  delirium  or  vomiting ;  and,  after 
all,  the  only  symptom  which  deserves  attention  is  the  paralysis.  It  is  im- 
portant to  bear  in  mind  that  rigidity  and  contracture  take  place  before 
paralysis,  while  we  know  that  the  converse  is  the  rule  in  cerebral  hem- 
orrhage. Should  hemiplegia  follow  a  number  of  the  other  symptoms,  we 
may  consider  that  the  hemorrhage  is  secondary  to  the  cerebritis,  and  that 
some  vessel  has  been  cut  across.  It  is  almost  impossible  to  distinguish 
uncomplicated  cerebritis  from  meningo-cerebritis.  The  pain  is  perhaps 
more  marked  in  the  latter,  and  the  convulsions  are  bilateral,  and  apt  to 
be  local,  and  due  to  involvement  of  one  or  more  of  the  psychomotor  cen- 
tres. In  uncomplicated  cerebritis  there  is  not  nearly  so  much  fever  as  in 
the  meningeal  form  or  in  simple  meningitis.  Typhoid  fever  may  simu- 
late cerebritis,  and  vice  versa.  Attacks  of  the  latter  begin  with  headache, 
vertigo,  movements  of  the  eyes,  insomnia,  delirium,  nose-bleed,  and  diarr- 
hoea, with  high  evening  temperature.  The  absence  of  tympanites,  and 
gurgling  in  the  left  iliac  fossa,  and  the  apiDcarance  of  paralysis  and  visual 
disorders,  are  quite  sufficient  landmarks  to  prevent  the  diagnostician 
from  losing  his  way.  When  there  is  suspicion  of  otitis  or  traumatism,  it 
is  exceedingly  difficult  to  make  a  diagnosis  from  thrombosis  of  the  cere- 
bral sinuses,  and  it  is  fortunate  that  no  value  is  to  be  attached  to  such  a 
diagnosis,  as  far  as  therapeutical  indications  are  concerned. 

Prognosis. — There  is  very  little  hope  for  the  patient,  and  should  he 
survive  the  acute  attack  he  is  usually  left  paralytic  and  demented.  If 
there  be  a  purulent  accumulation,  which  becomes  encysted,  the  chances  of 
recovery  are  very  little  better,  and  it  only  becomes  a  question  of  time 
when  the  patient  will  die.  If  there  be  such  a  cerebral  abscess,  subsequent 
symptoms  very  much  like  those  connected  with  other  brain  tumors  will 
be  probably  developed  ;  but,  in  numerous  cases  cited  by  various  authors, 
a  cerebral  abscess  has  existed  unsuspected  for  years. 

Treatment. — Acute  cerebritis  in  either  form  must  be  met  with  ab- 
straction of  blood,  cold  effusions  to  the  head,  agents  which  lower  vascular 
tension,  counter-irritants,  and  mercury  in  some  one  of  its  forms.  The  ice- 
bag,  or  the  apparatus  already  alluded  to  for  the  application  of  cold  wa- 
ter, may  be  used,  and  leeches  are  to  be  applied  to  the  arms  or  behind  the 
ears.  Jaccoud  and  most  of  the  clinical  teachers  recommend  purgation, 
which  may  be  obtained  by  the  use  of  the  compound  jalap  powder,  fol- 
lowed by  calomel  carried  almost  to  the  point  of  salivation.  This  seems 
to  me  to  be  rather  energetic  treatment ;  and  I  think  that  the  purgative 
alone,  with  just  sufficient  calomel  afterward  to  insure  moderate  cathartic 
action,  is  preferable.  For  the  purpose  of  diminishing  vascular  tension, 
either  tartar  emetic,  aconite,  or  veratrum  viride  may  be  used.  Should 
the  cerebritis  be  found  to  depend  upon  syphilis  or  lead,  the  iodide  of  po- 
tassium may  be  employed  as  the  most  serviceable  remedy.  Blood-letting 
is  admissible  in  serious  cases,  and  is  recommended  by  nearly  all  of  the 
older  writers.  The  head  may  be  shaved  and  blistered,  or  cauterized ;  but 
I  am  convinced  that  sub-occipital  vesication  is  in  every  way  as  good,  and 


170        DISEASES   OF    THE    CEREBRUM    AND    CEREBELLUM, 

the  infliction  of  this  punishment  incident  to  general  cauterization  of  the 
head  is  not  warranted.  Some  German  writers  recommend  the  application 
to  the  shaven  scalp  of  tartar-emetic  ointment,  or  croton  oil,  and  claim 
good  results.  If  there  be  any  otitis,  it  is  well  to  promote  otorrhoea ;  or,  if 
there  be  a  collection  of  pus  beneath  a  depressed  and  fractured  bone,  it 
may  be  liberated  by  a  free  incision. 

CHRONIC   SOFTENING. 

Definition. — A  disease  of  the  brain  of  a  very  serious  character,  gene- 
rally of  a  secondary  nature,  and  dependent  upon  impaired  nutrition  of 
the  brain-substance  through  occlusion  of  the  cerebral  vessels,  and  symp- 
tomatized  by  a  numerous  variety  of  mental,  sensorial,  and  motorial  symp- 
toms, such  as  mania  or  melancholia  and  subsequent  dementia,  headache, 
and  cutaneous  hyperse^thesia  and  paralysis  and  convulsions. 

Symptoms. — Much  confusion  has  resulted  from  the  use  of  a  variety 
of  terms,  such  as  "  red  softening,  "  white  softening,"  "  inflammation  of 
the  brain,"  and  other  names  which  tend  to  mislead  the  student.  For  our 
purpose  it  will  do  to  consider  white  and  red  softening  as  different  stages 
of  the  same  condition,  which  may  result  from  a  variety  of  causes  ;  and 
inflammation  of  the  brain  more  as  the  condition  which  I  have  just  de- 
scribed than  that  of  which  I  propose  to  speak,  viz.,  the  variety  spoken  of 
by  Reynolds  and  others  as  "  non-inflammatory  softening."  The  symp- 
toms of  softening  of  the  brain  may  follow  a  cerebral  hemorrhage,  embo- 
lism, or  thrombosis,  or  perhaps  be  connected  with  symptoms  of  cerebral 
tumor;  or,  again,  cerebritis  may  leave  behind  it  a  chronic  condition  ex- 
pressed by  the  symptoms  I  am  about  to  detail.  The  early  troubles  of  the 
primary  form  are  those  of  intelligence;  the  patient  loses  his  memory  of 
events  which  have  recently  transpired,  is  unable  to  concentrate  his  atten- 
tion, becomes  silly,  restless  and  irritable,  quarrelling  with  his  immediate 
friends,  and  usually  getting  quite  excited  towards  night.  His  speech  may 
become  affected,  and  he  sits  by  himself  for  hours  during  the  day,  and 
mutters  constantly  a  mass  of  disconnected  rubbish.  This  condition  ol 
stupidity  increases ;  he  may  become  drowsy  and  complain  of  headache, 
with  feelings  of  head-pressure  ;  he  may  tell  us  that  his  limbs  feel  heavy, 
and  complains  of  muscular  pain,  from  which  he  suffers  in  the  attempt  to 
make  any  movement.  As  to  other  sensory  disturbances,  hypersesthesia  is 
much  more  common  than  ausesthesia;  though  cutaneous  areas  in  which 
sensation  is  impaired,  are  by  no  means  rare.  Motorial  troubles  are  of 
later  appearance,  commencing  with  gradual  loss  of  power  of  an  irregular 
character,  which  affects  either  the  arms  or  legs  in  the  beginning,  but 
finally  becomes  general.  This  paralysis  is  not  always  constant,  thei'e  be- 
ing a  greater  loss  of  power  at  times  than  at  others.  The  first  indication 
of  the  motorial  trouble  may  appear  either  in  the  execution  of  some  ordi- 
nary act,  which  will  be  performed  very  clumsily  ;  or  it  may  be  shown  in 
locomotion,  when  the  patient  will  stumble  or  fall  to  the  ground,  as  there 
may  be  a  sudden  giving  way  at  the  knee.  When  he  walks  he  scarcely 
lifts  his  feet  from   the  ground,  but  drags  them  after  him  in  a  helpless 


CHROKIC    SOFTENING.  171 

manner.  With  the  paralysis  there  may  be  a  certain  amount  of  rigidity, 
or  tonic  spasms,  affecting  the  muscles,  so  that  there  are  occasionally  spas- 
tic contracti  ais,  which  last  for  some  little  time.  Epileptiform  convulsions 
often  occur  during  the  disease,  as  well  as  attacks  of  mania,  which  are  quite 
violent.  When  the  softening  is  secondary,  and  follows  an  attack  of  em- 
bolism, thrombosis,  or  cerebral  hemorrhage,  the  initial  symptoms  make 
their  appearance  in  from  one  to  two  weeks  after  the  occurrence  of  the 
hemiplegia.  The  troubles  of  intelligence  are  those  which  first  attract  our 
attention,  and  are  generally  connected  with  high  temperature  and  severe 
headache.  The  patient  may  become  delirious  ;  he  indulges  in  delusions, 
and  grows  abnormally  sensitive;  or,  on  the  other  hand,  be  is  drowsy,  stu- 
pid, and  melancholic  ;  and  after  this  may  follow  paralytic  contractures, 
fibrillary  contractions,  clonic  spasms,  convulsions  resembling  epilepsy  ; 
and  he  may  finally  fall  into  a  state  of  coma.  It  is  not  uncommon  for  him 
to  involuntarily  joass  his  feces  and  urine.  With  the  formation  of  cysts  or 
abscesses,  which  constitute  a  late  result  of  cerebral  softening,  convulsions 
of  an  epileptoid  character  may  make  their  appearance  ;  or,  should  the 
condition  be  acute,  and  result  from  otitis,  as  is  the  case  in  cerebritis, 
these  as  well  as  other  symptoms,  may  be  among  the  first  to  develop.  Af- 
fections of  speech  are  quite  symptomatic  of  softening,  because  in  so  many 
of  the  eases  the  middle  cerebral  artery  is  that  obstructed  or  destroyed. 
The  hemiplegia,  which  may  occur,  is  unattended  by  any  loss  of  con- 
sciousness, aud  electro-muscular  contractility  is  generally  perfect  or  even 
exaggerated. 

The  following  may  be  presented  as  an  illustrative  case  : — 

J.  A.,  aged  45.  The  patient  was  brought  to  me  by  his  wife  during  the 
summer  of  1872.  Four  years  before,  while  actively  engaged  in  business 
which  demanded  the  most  devoted  attention,  and  required  a  great  deal 
of  intellectual  labor,  he  began  to  suflTer  from  headaches  limited  to  the 
frontal  region.  These  were  so  severe  that  while  engaged  in  his  office  he 
was  obliged  to  bind  a  wet  towel  about  his  head.  He  suffered  very 
greatly  from  insomnia,  and  found  it  impossible  to  sleep  unless  he  took 
large  doses  of  opium.  He  very  often  awoke  in  the  night,  and  went  upon 
the  house-top  or  out  into  the  street,  wandering  about  the  city  until  morn- 
ing. He  became  very  moody,  treated  his  wife  with  indifference,  and 
scolded  his  children  without  cause.  He  could  not  talk  for  five  minutes 
at  a  time  without  rising  and  pacing  furiously  about  the  room,  while  he 
seemed  to  be  annoyed  by  the  slightest  noises  about  the  house.  The  trick- 
ling of  water  from  the  pipe  over  the  water-closet  tank,  which  was  next 
to  his  bed-room,  so  annoyed  him  that,  in  a  fit  of  impatience  and  un- 
governable irritability,  he  wanted  to  send  for  the  plumber  in  the  middle 
of  the  night.  His  wife  persuaded  him  to  consult  a  homoeopathic  physi- 
cian, by  whom  he  was  treated  for  nearly  a  year,  and  at  the  end  of  that 
time  went  abroad.  He  had  meanwhile  grown  much  worse,  his  mental 
state  was  much  more  aggravated,  and  his  headaches,  though  not  so 
severe,  were  still  constantly  present.  He  complained  of  formication  of 
the  soles  of  the  feet,  and  his  gait  was  markedly  affected,  both  feet  being 
scarcely  lifted  from  the  ground  and  he  dragged  one  after  the  other  when 
he  walked.     He  lost  rapidly  ia  flesh,  and  though  the  sea-voyage  did  him 


172  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

some  good,  he  relapsed  into  his  previous  state  after  he  reached  Europe. 
While  in  Switzerland  he  had  an  epileptiforna  attack,  and  after  recovery 
found  that  his  right  side  was  paralyzed.  His  speech  was  affected,  and 
from  what  I  can  learn  he  must  have  been  aphasic.  The  paralysis  im- 
proved in  a  short  time,  and,  strange  to  say,  his  mental  condition  also 
underwent  a  change  for  the  better.  After  a  few  months  he  returned  to 
New  York,  when  I  saw  him. 

He  was  then  in  an  almost  helpless  condition,  and  needed  the  assistance 
of  a  cane  and  his  nurse's  arm  to  make  any  progress.  He  was  bent  over, 
and  his  chin  was  depressed,  so  that  it  almost  touched  his  chest.  The 
mouth  was  open,  and  the  lower  lip  drooped  slightly  ;  while  from  the  cor- 
ners of  the  mouth  there  was  an  escape  of  saliva  which  trickled  down  over 
his  chin.  His  face  bore  a  very  vacant  look,  and  when  he  attempted  to 
speak  it  was  clouded  by  an  anxious  and  discontented  expression,  which 
arose  probably  from  the  vexation  he  felt  at  being  unable  to  speak.  Pho- 
nation  w^as  not  affected,  but  w^ord  formation  seemed  entirely  lost,  so  that 
his  attempts  to  speak  consisted  in  the  production  of  disorderly  noises,  the 
tongue  being  used  extensively,  the  lips  not  participating.  He  could  not 
protrude  his  tongue  when  told  to  do  so.  His  right  pupil  was  larger  than 
the  left.  His  right  side  was  partially  hemiplegic,  and  his  wife  stated 
that  the  loss  of  power  was  greater  at  times  than  at  others.  The  right 
fore-arm  was  slightly  flexed  upon  the  arm,  and  the  fingers  seemed  rigid. 
His  control  over  the  bladder  was  partially  lost,  and  very  often  he  would 
void  his  urine  while  upon  the  street,  or  at  night.  There  is  a  history  of 
trembling  which  affects  the  right  arm  and  leg.  This  occurs  during  quies- 
cence, and  seems  to  have  no  connection  with  voluntary  movements.  His 
appetite  is  voracious,  but  there  appears  to  be  some  difficulty  in  swallow- 
ing, so  that  it  is  found  necessary  to  cut  up  his  food.  About  two  weeks 
ago  he  had  a  slight  epileptoid  attack.  During  warm  days  he  seems  dis- 
posed to  sleep  a  great  deal ;  but  when  excited  by  the  presence  of  disagree- 
able people,  or  thwarted  or  crossed,  he  becomes  extremely  violent,  and  even 
dangerous.  I  saw  him  but  once,  and  he  was  afterwards  sent  to  an  asylum. 

An  extremely  interesting  form  of  cerebral  disease  of  this  character,  is 
that  occurring  in  syphilitic  subjects,  and  attended  by  narrowing  of  the 
vessels,  with  inflammation  of  their  inner  coats,  the  so-called  syphilitic 
endoarteritis.  There  is  consequent  diminution  in  nourishment  of  large 
tracts  of  brain  substance,  extensive  anaemia  and  softening. 

The  clinical  features  of  such  changes  are  numerous.  In  some  cases 
the  symptoms  of  non-specific  thrombosis  are  presented,  but  the  hemi- 
plegia is  rarely  preceded  by  unconsciousness.  Epileptiform  attacks, 
severe  nocturnal  headache,  and  impairments  of  the  mental  powers  are 
conspicuous,  while  a  very  suspicious  indication  of  the  specific  nature  of  the 
trouble  is  local  paralysis  of  the  cranial  nerves.  The  symptoms  develop 
sometimes  very  quickly,  and  may  disappear  with  great  rapidity  under 
anti-syphilitic  treatment,  or  on  the  contrary,  if  there  be  much  mental 
enfeeblement,  I  have  found  the  pi'ognosis  to  be  grave  in  the  extreme. 

^  Chauvet,   *  Fournier,   and   ^  Mickle,   and    others    have  described   a 

1  Influence  de  la  Syphilis  sur  les  M.  du  S.  N.,  1880. 

2  La  Syphilis  du  Cerveau,  1879. 

^  Br  and  Foreign  Med   Chir.  Raview,  April,  1877. 


CHRONIC    SOFTENING.  173 

spurious  form  of  general  paralysis,  which  is,  in  reality,  a  form  of  cerebral 
softening.  It  is  the  same  disease  as  that  denominated  by  Voisin — 
rencejjhalopathie  syphilitique.  In  this  pseudo-general  paresis  there  is 
hebetude,  delirium  and  incoherence.  Unlike  true  general  paresis,  how- 
ever, the  insane  delusions  do  not  possess  the  extravagance  of  the  latter, 
and  there  is  very  little  of  the  boasting  and  inordinate  vanity. 

The  disorders  of  motility  are  not  so  conspicuous  as  in  the  well  recog- 
nised disease  of  non-specific  origin,  for  there  is  not  so  much  tremor. 
Labial  tremor,  according  to  Mickle,  is  much  less  common  and  violent, 
and,  he  says,  that  where  such  tremor  exists  it  is  always  preceded  by 
paralytic  troubles,  which  is  not  the  case  in  the  ordinary  paresis.  An  at- 
tack of  hemiplegia  is,  as  a  rule,  the  first  indication  in  the  syphilitic  subject, 
and  the  patient  presents  the  peculiar  cachectic  appearance.  A  symptom 
referred  to  in  another  part  of  this  work,  and  one  which  is  pathognomonic, 
I  believe,  is  the  peculiar  asthenic  character  of  the  mental  trouble. 
There  is  a  true  enfeeblement  of  the  intellect,  which  in  some  respects,  re- 
sembles dementia.  Memory,  in  regard  to  remote  events,  appears  to  be 
blunted,  as  well  as  in  regard  to  events  that  have  occurred  recently. 
There  is  not,  of  necessity,  much  emotional  'irritability  upon  the  part  of 
the  patient,  although  early  in  the  trouble  there  is  sometimes  cerebral 
irritation  and  mental  excitement.  A  disposition  to  sleep  is  not  rare,  and 
such  sleep  is  usually  quiet  and  may  even  approach  stupor.  In  cases 
of  syphilitic  cerebral  disease  of  every  kind,  the  careful  practitioner 
should  be  on  the  lookou.t  for  tertiary  skin  lesions  and  evidences  of  early 
general  symptoms.  In  cases  I  have  treated  from  time  to  time  there 
has  been  severe  neuralgia,  which  was  much  more  intense  at  night  than 
during  the  daytime,  and  besides,  the  facial  and  sub-occipital  pain  there 
has  been  a  sense  of  vertical  head  pressure.  The  localized  paralysis  may  in- 
volve organs  which,  as  a  rule,  escape  involvement  in  organic  disease.  In 
three  of  my  cases  there  has  been  aphonia  as  a  result  of  paralysis  of  the 
vocal  cords,  and  in  one  of  these  cases  there  was,  in  addition,  paralysis 
of  the  third  nerve,  and  in  another,  alternating  hemiplegia. 

Causes. — First  and  foremost  are  primary  fornfs  of  disease,  which 
either  produce  occlusion  of  an  artery,  or  irritation  from  alblood-clot  or 
tumor.  Vascular  degeneration,  which  may  result  from  general  disease, 
or  renal  trouble,  acts  as  a  predisposing  cause  in  the  development  of  cere- 
bral softening.  Intellectual  fatigue,  sexual  excitement,  alcoholic  intoxi- 
cation, head  injuries,  and  local  disease  act  as  exciting  causes.  Exposure 
to  cold  has  been  given  as  a  cause  of  cerebral  softening,  and  exposure  to 
the  direct  rays  of  the  sun  may  induce  the  condition.  Bamberger  ^  has 
observed  it  as  a  consequence  of  typhus  and  acute  articular  rheumatism  ; 
and  Jaccoud  ^  considers  that  it  may  be  jDroduced  by  syphilis  in  two 
different  ways,  either  by  a  gummy  tumor,  which  gives  rise  to  irritation  of 


Wiirtzburg  Verhandlungen,  1856. 
Pathologie  Interne,  torn,  i,  p.  177. 


174  DISEASES     OF     THE     CEREBKUM     AXD     CEREBELLUM. 

the  tissue  in  the  neighborhood,  or  by  infiltration.  According  to  Fournier 
and  Huebner,  syphilitic  cerebral  trouble  may  begin  as  late  as  the  twen- 
tieth year  of  the  disease,  and  according  to  the  latter,  as  early  as  the  first 
year,  though  it  is  usually  until  three  or  four  years  after  the  primary 
sore. 

Cerebral  softening  is  more  common  among  people  of  an  advanced  life 
as  an  idiopathic  affection,  and  unless  it  follows  embolism,  injuries,  or  like 
causes,  is  quite  rare  in  early  life,  Andral  having  found  only  39  cases  out 
of  153  in  persons  under  40.  Djrand-FardeP  presents  the  following  sta- 
tistics regarding  the  period  of  life  at  which  the  softening  began: — 

From     30  to  40 3 

40  "  50 8 

50  "  55 2 

60  "  65 5 

66  "  70 9 

71  "  75 13 

76  "  80 10 

80  "  87 5 

Jaccoud  is  of  the  opinion,  which  others  hold,  that  males  are  more 
commonly  affected  than  females.  Season  has  nothing  to  do  with  its  de- 
velopment. 

Morbid  Anatomy  and  Pathology.  —-There  has  been  great  differ- 
ence of  opinion  in  regard  to  the  patholog}'  of  brain  softening.  Those  who 
described  it  in  the  early  part  of  the  century  considered  it  to  be  an  inflam- 
matory affection,  while  Rostan,^  who  reported  many  cases,  recognized  a 
non-inflammatory  form  which  he  had  met  with  among  old  people  with 
rigid  arteries.  As  Russell  Reynolds^  very  properly  observes,  '•  much  con- 
fusion has  arisen  from  a  tendency  to  misinterpret  morbid  anatomical  ap- 
pearances, without  paying  sufiicient  attention  to  their  mode  of  origin." 
Cruveilhier*  considered  two  forms,  one  of  which  was  apoplectic,  or  "  apo- 
plexie  capillaire,"  which  he  did  not  consider  inflammatory;  and,  later, 
AndraP  announced  his  disbelief  in  the  necessarily  inflammatory  origin  of 
the  disease,  and  considered  it  due  to  occluded  arteries  and  insuflicient  nu- 
trition. Among  the  powerful  advocates  of  the  inflammation  theory  are 
Durand-Fardel^  and  Gluge,'  while  upon  the  other  side  may  be  mentioned 
such  additional  names  as  Kirkes,''  Laborde,'  Hughiings  Jackson,'"  and 
many  others.  It  may  be  said,  I  think,  that  softening  of  the  brain  is  nearly 
always  of  an  inflammatory  character  when  it  follows  head  injury  and  dis- 
eases of  the  cranial  bones,  while  the  majority  of  cases,  which  are  second- 

1  Traite  du  KamoUisement,  etc.     Paris,  1843.     P.  491. 

2  Recherche?  snr  le  Rimolliseraent  da  Cerveau,  1820. 

3  System  of  Medicine,  vol.  ii.  p.  461.  *  Etude  de  Ii  Med.,  etc.,  1821. 
'"  Precis  d' Anatomic  Path.,  1829. 

*  Traite  du  Ramollisement  du  Cerveau,  Paris,  1843,  and  Maladies  des  VeillarJs. 
^  Comptes  Eendup,  1837.  "  Op.  cit.,  vol.  xxxv.  p.  821. 

^  Le  Ram.  et  la  Cong,  du  Cerveau,  Paris,  1859.  '"  Op.  cit. 


CHRONIC   SOFTENING. 


175 


ary  to  occlusion  of  vessels,  are  dependent  upon  general  disease  o'f  a  non- 
inflammatory nature. 

If  the  disease  be  primary,  Jaccoud  considers  that  the  lesion  will  be  of 
the  first  form,  that  is,  at  a  single  point ;  but  that  when  the  softening  fol- 
lows typhus  fever,  puerperal,  and  other  general  diseases,  the  foyers  will  be 
multiple.  If  the  softening  results  from  embolism  or  thrombosis,  or,  in 
fact,  from  any  other  condition  producing  obstruction  of  the  circulation, 
there  will  first  be  a  congestion  with  exudation  of  serum,  hypersemia  of  the 
vessels,  and  perhaps  capillary  hemorrhage,  which  is  attended  by  colora- 
tion of  the  parts  in  the  neighborhood,  so  that  they  become  of  a  bright 
pink  or  red  color,  and  are  limited  by  other  regions,  which  are  ansemic 
and  blanched,  and  a  condition  which  has  been  called  "  red  softening"  ex- 
ists. If  this  morbid  process  takes  place  in  the  gray  matter,  the  hemorr- 
hagic spot  will  be  of  a  much  darker  color,  and  much  more  sharply  circum- 
scribed. The  next  change  takes  place  within  a  week  or  two,  when  the 
color  of  the  lesion  becomes  much  more  pale,  and  the  exudation  granu- 
lar; fatty  degeneration  takes  place,  the  softened  spot  extends,  the 
neuroglia-cells,  nerve-fibres,  and  nerve-cells  become  disintegrated,  the  axis 

Fig.  28. 

Diagrammatic. 


TrsSTTE  Changes  in  Softening.    A.  Vessel.    B,  B,  C.  Nerve-tubes.    D.  Gluge's  corpuscles.    E.  Swollen 

nerve-tube. 


cylinders  disappear,  and  the  bloodvessels  alone  may  be  distinguished,  and 
even  they  are  greatly  disorganized.  At  this  stage  the  softened  spot  be- 
comes much  paler,  is  creamy  in  consistence,  and  contains  stringy  flakes  of 
a  fibrinous  nature.  It  is  extremely  rare  for  resolution  to  take  place  even 
in  the  earliest  stage.  A  form  of  softening,  alluded  to  by  Jaccoud,  Du- 
rand-Fardel,  and  others,  consists  in  the  formation  of  yellow  plates,  chiefly 
in  the  convolutions  (plaques  jaunes)  which  are  the  result  of  a  partial 
metamorphosis  of  the  softened  patches.  There  may  be  also  a  retrograde 
change,  as  is  witnessed  in  the  formation  of  cysts,  which  are  filled  by  a 


176       DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

chalky  fluid  containing  fat  globules.  There  is  always  i^resent  a  variety 
of  cells  known  as  Gluge's  globules,  which  are  composed  of  collections  of 
small  granular  bodies,  sometimes  surrounded  by  a  cell  wall,  and  these  are 
produced  by  the  degeneration  of  neuroglia-cells,  the  debris  of  which  are 
aggregated  as  masses  of  fatty  granules.  These  little  bodies,  which  rarely 
exceed  5J0  of  an  inch  in  diameter,  have  been  found  by  Reynolds,  Turck, 
and  Bouchard  in  the  cord,  where  their  form  of  origin  is  the  same. 

The  various  (colors  may  be  seen  in  the  brain  at  the  same  time,  patches 
of  red,  brown,  yellow,  or  white  denoting  different  stages  of  the  morbid 
process.  The  lighter  shades  generally  indicate  advanced  stages,  such 
being  the  opinion  of  Durand-Fardel.  Charcot  and  various  observers  have 
found  forms  of  white  softening  in  old  people ;  and  others,  among  them 
Cotard,  Prevost,  Bastian,  and  Reynolds  have  seen  cases  of  the  same  kind. 
It  is  extremely  doubtful  whether  the  condition  of  degeneration  was  not 
preceded  by  some  exudation  of  blood-elements,  and,  if  it  was  not,  whether 
the  condition  had  not  been  confounded  with  sclerosis.  Softened  patches 
may  be  in  the  second  stage  removed  by  allowing  a  stream  of  water  to  fall 
upon  the  cut  surface,  and  when  the  disorganized  tissue  is  washed  away  a 
depression  is  left.  If  the  cut  be  made  through  a  brain  which  presents  the 
appearance  of  red  softening,  the  affected  patch  will  be  found  to  stand 
slightly  above  the  normal  tissue,  and  this  is  probably  due  to  a  hyperemia 
of  the  capillaries  of  the  part.  This  fulness  of  the  capillaries  is  undoubtedly 
due  to  collateral  circulation  of  blood  through  the  vessels  contiguous  to  that 
obliterated,  the  normal  functions  being  increased  through  double  duty  im- 
posed upon  them.  This  is  the  view  held  by  Weber,^  as  well  as  by  Prevost 
and  Cotard.'^ 

If  the  yellow  appearance  of  the  softened  patches  be  not  due  to  altered 
coloring  matter  of  the  blood  such  as  Ave  find  in  the  early  stages,  it  may 
be  found  later  in  connection  with  gelatinous  circumscribed  masses  scat- 
tered through  the  brain  or  about  old  clots  or  tumors. 

The  parts  most  liable  to  this  change  both  in  chronic  and  acute  forms 
are  the  corpora  striata,  optic  thalami,  white  substance  of  the  hemispheres, 
and  sometimes  the  cerebellum ;  or  there  may  be  multiple  foyers  scattered 
through  different  parts  of  the  brain. 

Durand-FardeP  has  collected  sixty-two  cases  of  his  own  and  from  the 
writings  of  other  authors,  in  which  the  locality  of  the  softening  was  the 
following : — 

Convolutions  and  white  substance 22 

Convolutions  alone 6 

White  substance  alone 5 

Corpus  striatum  and  optic  thalamus 6 

Corpus  striatum  alone 11 

Optic  thalamus  alone 4 

1  Handbuch  der  Allgem.  und  Spec.  Chirur.,  1865. 

2  Gaz.  Med.  de  Paris,  May  19,  1866,  p.  336. 
'  Op.  cit.  p.  2. 


CHRONIC    SOFTENING.  177 

Pons  Varolii 3 

Crus  cerebri .    1 

Corpus  calloRum 1 

Walls  of  the  ventricles  (septum) 1 

Fornix 1 

Cerebellum .1 

The  invasion  of  tlie  brain  by  syphilis  is  usually  coincident  with  that  of 
other  organs,  notably,  the  liver.  The  morbid  process  prefers  the  central 
arteries,  but  those  of  small  size  in  every  part  of  the  brain  may  be  the 
general  seat  of  inflammation  and  narrowing,  and  as  a  consequence  a  large 
mass  of  nervous  tissue  may  be  deprived  of  its  nourishment  and  undergo 
an  alteration  resembling  that  which  attends  non-specific  softening.  The  ir- 
ritation of  the  syphilitic  virus  undoubtedly  sets  up  an  inflammatory  process 
beneath  the  endothelium  of  the  vessel  with  deposit  of  granular  substance, 
nuclei  and  spindle-shaped  cells.  There  is  thickening  of  the  endothelium 
and  separation  of  this  coat  from  the  others.  Subsequent  organization  of 
the  sub-endothelial  deposit  and  division  with  strata.  The  vessel  becomes 
surrounded  by  new  tissue  which  is  also  more  or  less  organized  and  is  ulti- 
mately supplied  by  capillaries.  The  next  stage  is  marked  by  closure  of 
the  vessel. 

Diagnosis. — In  an  excellent  lecture  delivered  by  Hughlings  Jack- 
son,^ he  says :  "  I  do  not  see  how  the  diagnosis  that  there  is  actual  soften- 
ing of  the  brain  is  in  any  case  to  be  possibly  arrived  at,  unless  the  ])atient 
has  certain  local  2?aralytic  symptoms,  as  hemiplegia,  or  some  other  symptoms 
implying  a  local  cerebral  lesion,  such  as  affection  of  sjjeech;  or,  again,  un- 
less there  be  signs  of  cerebral  tumor  (severe  headache,  urgent  vomiting, 
and  double  optic  neuritis)  or  evidence  of  injury  to  the  head.  For,  so  far 
as  I  know,  cerebral  softening  is  always  local ;  I  know  nothing  of  general 
or  universal  softening  of  the  brain.  To  be  warranted  in  diagnosing  soft- 
ening, you  must  have  symptoms  which  point  to  local  disease.  I  do  not 
say  that  local  cerebral  softening  cannot  exist  without  localizing  symptoms. 
I  only  say  that  in  their  absence  you  are  not  warranted  in  diagnosing  its 
existence."  This  remark  is  made  in  connection  with  the  lecturer's  disbe- 
lief in  various  forms  of  functional  disease  which  are  so  often  improperly 
called  "  softening,"  and  in  which  a  few  functional  symptoms  which  disap- 
pear under  appropriate  treatment  are  vested  by  the  careless  or  unscrupu- 
lous practitioner  with  an  importance  they  do  not  deserve.  These  symp- 
toms are  those  which  follow  depraved  states  dependent  upon  venereal 
excesses,  fright,  and  other  causes  which  lower  the  tone  of  the  nervous 
system.     Jackson's  warning  is  a  pertinent  one. 

If  we  have  hemiplegia,  some  renal  or  cardiac  disease,  and  valvular  de- 
posits, with  murmurs,  our  suspicions  of  softening  generally  turn  out  to  be 
well  founded.  The  history  of  the  antecedent  attack,  should  it  be  throm- 
bosis, embolism,  or  cerebral  hemorrhage,  has  much  to  do  with  the  making 
of  a  correct  diagnosis.     As  I  have  said,  hemiplegia,  unattended  by  loss  of 

*  London  Lancet,  Sept.  4,  1875. 
12 


178        DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

consciousness  at  the  outset,  is  a  diagnostic  point  in  favor  of  softening, 
and  suggests  embolism,  and  if  the  train  of  symptoms  given  on  a  previous 
page  is  afterwards  expressed,  there  can  be  little  doubt  as  to  the  nature  of 
the  disease.  A  point  insisted  upon  by  Jackson  is  that  the  general  mental 
symptoms  of  softening  are  either  expressed  before  the  softening,  or  follow 
it.  He  denies  that  general  mental  symptoms  (wandering,  delusions,  etc.) 
are  directly  caused  by  the  softening,  but  that  special  mental  symptoms 
(affection  of  speech)  are.  The  general  mental  symptoms  follow  a  few 
hours  or  days  after  the  local  softening.  The  "preceding  mental  symptoms  " 
are  irritability  and  altered  disposition. 

Chronic  meningitis  may  resemble  cerebral  softening,  but  in  the  former 
the  pain  is  more  diffused,  and  the  motorial  phenomena  (spasms,  etc.)  are 
more  pronounced.  Softening  with  tumor  may  be  made  out  from  the  ad- 
ditional presence  of  optic  neuritis,  choked  disk,  and  vomiting.  Some 
forms  of  progressive  meningitis,  such  as  pachymeningitis  -with  cerebral 
hsematoma  (vide  the  case  detailed  in  the  chapter  upon  pachymeningitis), 
may  closely  simulate  cerebral  softening,  and  very  often  the  diagnosis  is 
exceedingly  difficult,  or  may  be  impossible.  The  symptoms  of  hemor- 
rhage from  rupture  of  a  meningeal  vessel,  such  as  occurs  in  the  course  of 
these  chronic  varieties  of  meningitis,  may  closely  counterfeit  the  apoplec- 
tic attack  which  occurs  so  often  in  cerebral  softening. 

Prognosis. — Cerebral  softening  is  one  of  the  most  unfavorable  con- 
ditions with  which  we  are  acquainted.  Death  follows  the  establishment 
of  the  morbid  condition  sooner  or  later  in  nearly  all  cases  occurring  in 
adult  life.  An  occasional  case  of  recovery  may  be  encountered  in  a  young 
subject,  but  this  is  exceptional.  Of  109  cases  of  both  forms  of  cerebritis 
collected  by  Aitkin,^  he  found  that  the  duration  of  life  in  cases  of  this 
disease  was  the  following,  which  also  proves  that  there  are  more  cases  of 
the  acute  than  the  chronic  form  of  the  disease. 


1   died 

in  12  hours. 

2 

died 

in  12  days. 

died 

in  30 

days. 

1 

15 

" 

3 

(( 

13 

tt 

" 

36 

1 

24 

<i 

3 

(( 

15 

ti 

" 

47 

1 

32 

(< 

1 

<< 

16 

(< 

(( 

49 

5 

2  d 

ays. 

2 

i( 

17 

" 

« 

60 

9 

3 

" 

4 

(< 

18 

t( 

« 

65 

5 

4 

" 

5 

n 

20 

'' 

it 

68 

4 

5 

(< 

3 

11 

21 

« 

(• 

190 

7 

6 

(( 

1 

u 

12 

(( 

ti 

220 

8 

7 

It 

1 

it 

23 

(( 

it 

5  months 

8 

8 

« 

1 

<( 

25 

i< 

2 

tt 

6 

" 

3 

9 

<( 

1 

tt 

29 

tt 

1 

It 

1 

year. 

5 

10 

<i 

4 

It 

30 

(( 

2 

tt 

3 

years. 

4 

11 

The  greater  number  of  these  patients  died,  it  will  be  seen,  before  the 
twelfth  day. 

The  experience  of  other  observers  is  slightly  different  from  this,  as 

^  The  Science  and  Practice  of  Medicine,  vol.  ii.  p.  304. 


ASEMASIA.  179 

many  persons  with  secondary  softening  have  been  found  to  live  for  years 
after  the  commencement  of  the  softening.  These  cases  being  all  fatal, 
we  have  to  remember  as  well  that  there  are  many  instances  in  which 
an  abscess  forms  and  becomes  encysted,  or  the  non-inflammatory  soften- 
ing circumscribed. 

In  syphilitic  arterial  disease  the  prognosis  is  bad  when  the  mental 
symptoms  are  at  all  prominent ;  but,  light  symptoms  chiefly  of  cerebral 
irritation,  which  indicate  the  beginning  of  the  morbid  process  described 
upon  another  page,  are  sufiiciently  suggestive  to  enable  us  to  give  the 
patient  encouragement,  and  to  expect  benefit  from  energetic  anti-syphili- 
tic treatment. 

Treatment. — Our  efibrts  should  be  to  improve,  as  rapidly  and  fully 
as  possible,  the  patient's  general  condition.  For  this  purpose  we  must 
not  only  prescribe  for  him  a  hearty  hydrocarbonaceous  diet,  but  we  are 
to  insist  upon  cold-bathing,  out-door  exercise,  and  moderate  stimulation. 
As  medicaments,  I  am  positive  that  there  is  no  better  remedy  than  phos- 
phorus, which  may  be  given  in  combination  with  cod-liver  oil,  or  in  solu- 
tion in  absolute  alcohol.  The  bromides  may  be  given  in  combination 
with  lupulin,  if  there  be  headache  or  delirium  ;  or  cannabis  indica,  as 
recommended  by  Reynolds.  If  the  bowels  be  sluggish,  a  free  use  of 
saline  cathartics  is  of  great  benefit;  and  to  relieve  the  head  symptoms, 
leeching  may  do  much  good.  In  the  chronic  form  tonics  are  indicated, 
and  for  this  purpose  I  prefer  the  ammonio-citrate  of  iron.  I  am  not  in 
favor  of  strychnine,  and  should  hesitate  to  use  it  if  the  case  were  at  all 
acute. 

For  the  relief  of  the  syphilitic  form  of  disease  we  may  follow  the  treat- 
ment insisted  upon  by  Dr.  Taylor  and  others — "iodine  and  mercury  in 
heroic  doses." 

The  iodide  of  potassium  should  be  employed  in  commencing  doses  of 
fifteen  grains,  and,  if  borne  well,  may  be  increased  even  to  one  drachm 
three  times  a  day.  This  drug  should  be  given  well  diluted  and  after  eat- 
ing. Simultaneous  inunction  of  mercurial  ointment  greatly  helps  the 
action  of  the  iodide. 

ASEMASIA^  (APHASIA). 

Synonyms. — Aphemia,  Alalia,  Laloplegia,  Paralalie,  etc. 

Definition, — We  may  define  aphasia  (which  is  derived  from  the 
Greek  a,  priv.,  and  wa.ai':,  speech)  as  a  partial  or  complete  loss  of  speech, 
which  does  not  depend  upon  any  vocal  or  lingual  impairment  of  func- 

^It  has  occurred  to  me  that  the  word  "aphasia,"  as  at  present  used,  has  too  re- 
stricted a  meaning  to  express  the  various  forms  of  trouble  of  this  nature,  which  not 
only  consist  of  speech  defects,  but  loss  of  gesticulating,  power,  singing,  reading, 
writing,  and  other  functions  by  which  the  individual  is  enabled  to  put  himself  in 
communication  with  his  fellows.  I  would,  therefore,  suggest  "asemasia"  as  a  sub- 
stitute for  "  aphasia."  The  word  is  derived  from  a  and  ct]p.aivu,  (an  inability  to 
indicate  by  signs  or  language). 


180         DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

tion,  but  upon  disease  of  the  speech-centres,  whereby  the  origination  of 
forms  of  expression  is  suspended  or  deranged  to  a  greater  or  less  degree, 
or  a  kindred  loss  of  writing  or  gesticulating  power.  Aphasia  must  not 
be  confounded  with  aphonia,  or  with  the  condition  met  with  in  idiots  or 
mutes.  The  disease  we  are  about  to  consider  is  seated,  as  it  is  generally 
conceded,  in  the  third  frontal  convolution,  and  is  characterized  by  the 
disruption  of  the  connection  between  the  formation  of  ideas  and  their  ex- 
pression by  the  lingual  apparatus  ;  or,  as  Broca  has  expressed  it :  "  Le 
mot  aphasie  sert  aujourd'hui  a  designer  la  perte  ou  la  perversion  de  la 
faculte  du  langage ;  en  generale  c'est  de  cette  faculte  que  nous  permet 
d'^tablir  une  relation  constante  entre  une  idee  et  une  signe,  que  ce  signe 
soit  un  mot,  un  geste,  ou  un  trace  quelconque."  This  loss  of  function 
varies  from  temporary  trouble,  such  as  the  substitution  of  an  occasional 
wrong  word,  to  a  condition  of  decided  intellectual  abasement.  It  will  be 
well,  before  discussing  the  subject  further,  to  say  a  few  words  in  regard  to 
the  history  of  this  interesting  disease.  Our  first  information  comes  from 
very  early  writers,  among  whom  were  Sextus  Empiricus,^  who  lived  two 
hundred  years  before  Christ,  and  Pliny.  Trousseau  (p.  253)  quotes  the 
latter :  "  Illness,  falls,  a  mere  fright,  impair  it  (memory)  partially,  or 
destroy  it  completely.  A  man  struck  by  a  stone  forgot  the  letters  of  the 
alphabet,"  etc.  Later,  Sauvage,^  Cullen,'  and  the  two  Franks*  wrote 
most  exhaustively  during  the  seventeenth  and  eighteenth  centuries,  but 
all  of  these  authors  devoted  more  attention  to  mutism,  aphonia,  and  like 
conditions,  than  to  aphasia.  In  1840,  Lordat,^  who,  strange  to  say,  be- 
came aphasie  himself,  described  the  disease  under  the  name  of  alalia,  a 
term  used  by  Jaccoud  at  the  present  day.  Though  Gall/  as  early  as 
1808,  localized  the  speech-centre  above  the  orbits,  it  was  not  till  1825 
that  its  pathology  and  morbid  anatomy  were  clearly  settled  by  Bouil- 
laud,'  who,  working  upon  Gall's  theory,  enunciated  the  doctrine  that 
"  the  anterior  lobes  of  the  brain  are  the  organs  for  the  formation  and 
recollection  of  words,  or  the  principal  signs  which  represent  our  ideas." 

Afterwards,  Bouillaud's  views  were  nevei-theless  opposed  by  Andral/ 
Cruveilhier,"  and  others,  to  whom  I  shall  hereafter  allude.  Experiments 
made  by  Marce  in  1856,  and  by  others,  confirmed  all  that  Bouillaud  had 
stated.     The  next  step  was  taken  by  Marc  Dax'°  in  1836,  and  by  his  son, 

*  Translated  work  by  Huart,  Amsterdam,  1725,  p.  93. 
*No3ologia  Meth.,  Paris,  1722,  t.  ii.,  class  6,  p.  249. 

'  Synopsis  Nosologise  Meth.,  edited  by  Frank,  1787. 

*  De  Curandis  Horn.,  Mannheim  et  Vienna,  1792-1821. 

*  Analyse  de  la  parole  pour  servir  a  la  th^orie  du  divers  caad'alalieet  de  paralalie, 
etc.,  Montpellier,   1843. 

^Sur  les  Fonctions  du  Cerveau,  Paris,  1825,  t.  v. 

'Treatise  on  Encephalitis,  p.  284. 

« Maladies  de  I'Encfephale  (Clin.  M^d.,  1834,  t.  ii.). 

*Sur  le  principe  l^gislateur  de  la  parole  (Bull,  de  I'Acad^mie,  1839). 

'"Lesions  de  la  moiti^  gauche  de  I'encephale  coincidant  avec  I'oubli  des  signes  de 
la  pensee.  Memoir  read  at  the  Congr^  M^dicale  de  Montpellier,  1836 — Gaz.  Heb., 
April,  1865. 


ASEMA8IA. 


I8i 


who  confirmed  his  observations  in  1863.  It  was  the  younger  Dax  wfeo 
demonstrated  that  aphasia  was  connected  with  right-sided  paralysis^ 
Broca^  next  limited  the  spot  to  the  second  or  third  frontal  convolution. 
Since  then  Hughlings  Jackson/  Jaccoud/  Trousseau/  Dieulafoy/  GTaird- 
ner/  and  many  others  have  added  much  to  the  interest  of  the  subjeci'. 
There  has  been  considerable  discussion  as  to  the  proper  name  for.  the  af*- 
fection.  Lordat,  to  whom  I  have  already  alluded,  preferred  ^^.a^aZici;" 
and  others,  among  them  Broca,  denominated  the  condition  "  aplieniia. 
The  word  is  still  used  by  some  writers;  but  the  term  "  aphasia^'  has  come 
into  general  use,  and  is  generally  conceded  to  be  much  more  expressive 
and  proper  than  any  other,  but  it  has,  I  think,  been  too  indiscriminately 
employed.  '.       "   , 

Jaccoud,  who  has  rather  added  to  the  confusing  nomenclature^ presents 
a  table,  which  embodies  nothing  new,  and,  if  anything,  increases  the  iodeiv- 
niteness  of  our  knowledge  of  the  disease.  Aphasia,  or  more  properlyose- 
masia,  is  most  protean,  as  it  may  involve  the  power  of  reading  aloud,  speak- 
ing, writing,  and  gesticulating,  in  part  or  together,  in  a  number  of  curious 
ways.     Let  us  then  consider  the  phenomena  which  mark  its  existence. 

Speech. — The  vocabulary  of  the  aphasic  patient  is  generally  of  the  most 
limited  kind,  and  in  the  beginning,  should  the  condition  follow  a  cerebral 
accident  of  any  magnitude,  his  power  of  speech  is  totally  absent.  After 
a  while  he  may  be  able  to  command  one  or  two  short  phrases,  or  such 
words  as  "yes"  or  "no"  in  reply  to  every  question  that  may  be  asked. 
These  words,  or  such  as  have  become  automatic  from  constant  use,  are 
employed,  and  it  is  very  curious  sometimes  to  hear  the  patient  give  utter- 
ance to  some  phrase  which,  during  health,  he  has  constantly  and  some- 
times unconsciously  made  use  of.  In  other  instances  several  words  may 
be  joined  together  in  an  incongruous  manner ;  for  example,  it  was  ob- 
served, in  a  case  I  detailed  when  speaking  of  cerebral  thrombosis,  that 
the  patient  replied  "  When  Benny"  to  the  question  "  where  do  you  live?"* 

^Sur  le  siege  de  la  faculte  du  langage,  etc.  (Bull,  de  la  Soc.  Anat.,  2e,  Serie,  t.  iv., 
1861). 

»Gaz.  Heb.,  April  28,  1865. 

^Eep.  London  Hospital,  vol.  i.,  1864,  p.  388. 

*Gaz.  Heb.  July  and  Aug.,  1864. 

5  Clin.  Mfed.  de  I'Hotel  Dieu,  t.  ii.,  p.  571. 

8  Gaz.  des  Hop.,  June,  1865. 

'Arch,  de  Med.,  t.  ii.,  pp.  189-314,  1869.  The  reader  is  referred  to  the  admirable 
thesis  of  L^groux  (A.  Delahaye,  Paris,  1875),  for  a  more  complete  bibliography  of 
the  subject. 

*  Numerous  interesting  cases  are  reported.  One  described  by  Osborn*  is  illustrative 
of  a  form  which  is  sometimes  met  with.  The  patient  comprehended  written  language, 
and  expressed  himself  in  writing,  only  occasionally  transposing  words.  He  could 
translate  fluently,  and  was  able  to  calculate  arithmetical  sums.  He  could  not  pro- 
nounce the  letters  "k,  g,  w,  v,  w,  x,  and  z,"  and  the  letter  ''i"  seemed  to  puzzle  him. 
Dr.  Osborn  requested  him  to  read  the  following  sentence  from  the  By-Laws  of  the 
College  of  Physicians :  "  It  shall  be  in  the  power  of  the  college  to  examine  or  not  any 

*  Forbes  Winslow,  Obscure  Diseases  of  the  Mind,  p.  343. 


182        DISEASES    OF    THE    CEREBRUM     AND    CEREBELLUM. 

Durand-Fardel  alludes  to  a  patient  who  always  gave  the  following  absurd 
answer  :  "  Madame  ete,  mon  Dieu,  est-il  possible,  bon  jour,  madame." 
Legroux^  remarks  in  regard  to  these  forms  :  "  It  is  to  be  supposed  in  these 
cases  that  the  patients  speak  without  hearing  what  they  say,  or  that  their 
auditory  receptivity  is  unable  to  reveal  the  imperfection  of  their  speech." 
Occasionally,  however,  the  aphasic  is  conscious  of  the  absurdity  of  his 
reply;  he  Avill  laugh  in  a  silly  manner,  or  appear  annoyed  or  worried,  for, 
in  a  majority  of  cases,  there  is  perfect  mental  integrity,  and  the  position 
of  the  patient  is  very  like  that  of  a  man  driving  a  runaway  horse.  It 
has  often  reminded  me  of  a  condition  which  I  have  more  than  once  ex- 
perienced myself,  and  which  is  by  no  means  uncommon, — the  confusion 
of  the  mind  during  nightmare.  When  the  individual  is  about  to 
awake  he  is  semi-conscious  of  the  unsubstantial  character  of  the  impend- 
ing danger  of  the  dream,  but  cannot  save  himself  nor  can  he  awake. 
During  the  nightmare  a  person  may  actually  spring  from  the  bed,  or 
make  some  other  voluntary  attempt  to  escape.  Lordat,  who  was  aphasic, 
gave,  after  his  recoveiy,  an  account  of  the  inward  sensations  that  he 
felt  during  his  illness,  and  which  perfectly  indicate  the  part  played  by 
memory.  He  could  think,  he  could  co-ordinate  a  lecture,  or  change  its 
arrangement  in  his  own  mind,  but  he  was  unable,  although  he  was  not 
paralyzed,  to  express  his  thoughts  in  speaking  or  writing.  "  I  thought," 
said  he,  "  of  the  Christian  doxology,  '  Glory  be  to  the  Father,  the  Son, 
and  the  Holy  Ghost,'  and  I  was  not  able  to  recollect  a  single  word  of  it. 
Thoughts  seemed  to  arise  freely,  but  the  mode  of  expressing  them  in 
sounds,  the  receptacle  of  these  thoughts,  was  forgotten."^  The  words 
which  are  generally  lost,  and  are  the  latest  to  be  acquired,  are  the  pro- 
nouns and  substantives,  while  those  which  the  individual  retains  the 
power  of  articulating  more  than  any  other  are  the  interjections,  such  as 
"  Oh  !"  "oh,  dear !"  "  ah,  yes  !"  It  is  not  rare  for  patients  to  exhibit  two 
other  peculiarities  ;  one  is  a  substitution  of  other  words  for  those  intended, 
the  second  is  a  conjunction  of  incongruous  syllables  ;  for  instance,  a  pa- 
tient may  say  "  bel-eb  "  for  "  belief,"  or,  as  in  the  case  reported  by  Trous- 
seau, "  bon-tif"  was  substituted  for  "  bonsoir."  Some  persons  are  able  to 
repeat  words  which  are  first  pronounced  for  them  by  another,  but  are  un- 
able a  minute  afterwards  to  articulate  the  desired  word.  A  patient  of 
my  own,  when  requested  to  tell  what  it  was  he  held  in  his  hand,  could  not 
say.  When  asked  if  it  was  a  paper  he  shook  his  head  ;  an  apple  ? 
another  shake,  and  a  shrug  of  the  shoulder ;  a  cane  ?  a  pitying  smile,  and 
a  gesture  of  impatience ;  a  book  ?  a  bright  smile,  and  the  immediate  ar- 


licentiate  previous  to  his  admission  to  a  fellowship,  as  they  shall  think  fit."  The  re- 
sult was  as  follows :  "  An  the  hi  what  in  the  temother  of  the  tro  tho  todoo  to  ma- 
jorum  or  that  emidrate  ein  einkrastrai  mestreit  toketra  to  torn  breidei  to  ra  from- 
treido  as  that  kekritest."  It  is  rare,  however,  for  a  patient  to  accomplish  as  much  as 
this.  He  generally  becomes  impatient,  and  gives  up  the  attempt  after  half  a  dozen 
imperfect  words. 

'  De  1'  Aphasie,  p.  15. 

*  Trousseau's  Lectures  on  Clinical  Medicine,  vol.  ii.  p.  273,  last  Am.  edition,  1873^ 


ASEMASIA.  183 

ticulation  of  the  word  "  book."  "  What  did  you  say  it  was  ?"  To  which 
there  was  a  puzzled  look,  an  attempt  to  speak,  and  no  answer.  Jackson 
and  others  have  alluded  to  striking  examples  of  this  defect.  Bastian  ^ 
alludes  to  a  form  in  which  there  was  transposition  of  the  letters,  the  pa- 
tient saying  "gum"  for  "mug."  Patients  are  very  apt  to  substitute 
words.  Thus,  when  one  was  asked  if  he  wanted  to  sit  down,  replied : 
"  Give  me  a  bottle,  I  want  to  rise  down."  Bauduy  ^  alludes  to  a  case  where 
the  connection  was  better  shown.  The  man  asked  for  a  "  cup  of  cow!" 
Some  aphasics,  though  they  may  be  utterly  unable  to  speak,  can  sing. 
Hughliugs  Jackson^  alludes  to  two  aphasics,  boys,  one  eight  and  the  other 
ten,  who  could  sing.  Bacon  reported  the  case  of  an  idiot  boy  who  was 
aphasic,  but  could  sing  quite  cleverly.  These  cases  are  very  rare,  but  in- 
teresting examples  are  occasionally  brought  forward.  Behier  reports  the 
case  of  a  sailor  who  could  sing  the  Marseillaise,  using  the  word  "  tan  " 
throughout. 

Writing. — The  aphasic  individual  who  cannot  speak  is  occasionally 
able  to  write,  but,  in  my  experience,  I  have  generally  found  the  loss  of 
these  faculties  (speech  and  writing  power)  to  co-exist.  This  variety, 
which  has  been  called  agraphia  by  Ogle,  has  been  divided  by  him  into 
the  anemonemic  and  atactic  varieties.  We  may  meet  with  the  same 
peculiarities  which  attend  the  form  I  have  already  alluded  to,  viz. :  sub- 
stitution of  words  or  letters.  The  patient  may  be  able  to  write  after  a 
copy,  but  this  is  rare.  He  takes  his  pen  and  begins  quite  confidently,  but 
as  soon  as  the  pen  touches  the  paper  he  makes  a  series  of  scrawls,  which 
rarely  bear  any  resemblance  to  the  letters  forming  the  words  he  is  re- 
quired to  write. 

Bourneville*  relates  a  case  :  "  A  woman  named  Justine  Thomas  enter- 
ed the  hospital  La  Pitie  December  15,  1870,  and  was  assigned  to  the  ser- 
vice of  Marotte.  She  became  hemiplegic  on  the  right  side,  and  had  com- 
plete aphasia.  On  the  18th  of  December  the  hemiplegia  had  nearly  dis- 
appeared, but  the  aphasia  persisted.  At  this  time  she  was  asked  to  write 
her  name,  and  only  succeeded  in  producing  the  appearance  presented  in 
the  accompanying  cut  (Fig.  24,  J).  At  different  times  during  the  year 
specimens  of  her  handwriting  were  taken,  which  showed  progress  and 
marked  improvement,  the  last  attempt  being  made  in  November,  1871. 
(Fig.  24,  B.)  This  lost  power  must  not  be  confounded  with  other  con- 
ditions symptomatic  of  insanity  or  sclerosis  and  the  element  of  paralysis, 
which  should  be  taken  into  account  if  there  be  any  suspicion  of  a  loss  of 
muscular  power.  A  hemiplegic  may  be  unable  to  write  simply  through 
muscular  weakness  and  difficult  muscular  coordination.  Of  course  time 
will  enable  us  to  see  whether  the  inability  to  write  is  due  to  this  cause, 
or  is  really  the  "  agraphic  "  condition.     Reading,  singing,  and  the  power 

1  Med.  Chir.  Eev.,  xliii.  p.  209. 
'"■  Lancet,  1871,  p.  430. 
^  Diseases  of  Nervous  System,  p.  412. 
*  Legroux's  Thesis. 


184        DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

of  gesticulating  are  lost  either  separately  or  together.     A   person  who 
cannot  speak  is  sometimes  able  to  sing.     So,  too,  in  reading.     He  may 

Fi?.  24. 


read  mechanically  without  appreciating  the  sense,  or  may  drop  his  words 
or  substitute  others,  and  perhaps  is  unconscious  of  his  mistake.  He  may 
be  unable  to  read,  but  may  show  by  signs  that  he  knows  what  such  and 

Fig.  25. 


m 


Handwriting  of  two  patients :  "  A  "  being  affected  with  agraphia,  and  "  B  "  with  cerebrospinal 
sclerosis.  The  first  specimen  is  intended  for  "  Possible  to  see  you  on  Tuesday."  The  second, 
"  Dieu  et  mon  Droit." 

such  a  picture  may  be.  The  power  of  gesticulation  may  be,  and  often  is, 
lost.  He  may  make  attempts  to  describe  the  figure  of  some  object,  but 
cannot  do  so.  Trousseau  related  the  case  of  a  person  who  was  told  to 
imitate  the  playing  of  a  clarionet,  but  when  he  attempted  to  do  so  beat 
instead  an  imaginary  tambourine.  He  is  sometimes  able  to  count  figures 
which  are  before  him,  or  pieces  of  money  put  in  his  hand,  but  if  he  has 
no  such  reminders,  and  is  simply  told  to  count,  he  may  be  able  to  count 
up  to  a  certain  number,  and  say  ten,  and  does  so  in  a  peculiarly  auto- 


ASEMASIA.  185 

matic  way.     After  this,  when  some  thought  is  required  to  make  combi- 
nations, the  effort  is  unsuccessful. 

For  the  purpose  of  making  himself  understood  it  is  necessary  that  an 
individual  should  be  familiar  with  signs  (visual  and  auditory),  which  have 
been  received  either  upon  the  retina  or  tympanum,  and  reflected  upon 
certain  ideational  and  receptive  centres,  where  they  are  retained  and 
serve  as  models  for  expressions  the  individual  may  wish  to  make  in  the 
ftiture.  The  mental  process  which  attends  the  formation  of  language  or 
the  communicating  faculty  becomes  so  intricate  and  automatic  that  insen- 
sibly the  process  of  comparison  and  centre  stimulation  goes  on  without  the 
knowledge  of  the  person,  and  words  and  signs  are  made  upon  the  ground- 
work of  impressions  previously  received  for  guidance  and  formation.  It 
is  only  when  disease  affects  the  particular  centre  that  the  harmony  is  lost, 
and  the  patient,  though  possessing  the  ear  and  eye  as  mentors,  is  unable 
to  co-ordinate  the  mental  factors  of  intelligible  communication.  The  fa- 
cility for  connecting  ideas  with  sounds  or  signs,  which  is  a  normal  faculty, 
is  thus  spoken  of  by  Ogle :  "  This  faculty  of  converting  ideas  into  symbols 
is  quite  distinct  from  that  of  converting  symbols  into  ideas.  The  one  may 
be  acquired  or  lost  independently  of  the  other.  Thus,  a  child  learns  to 
interpret  the  language  of  others  before  it  can  itself  speak.  Adults,  as  a 
rule,  follow  the  same  order  in  learning  a  new  or  foreign  language.  Most 
of  us,  moreover,  know  what  it  is  to  have  the  pictured  map  of  some  familiar 
object  in  our  minds,  yet  to  be  perfectly  unable  to  call  up  its  name."  This 
defect  has  hitherto  been  supposed  to  depend  not  upon  the  apparatus  for 
the  receipt  of  impressions,  nor  upon  the  apparatus  for  communication,  but 
upon  a  loss  of  function  in  what  has  been  called  the  "  central  organ  of 
articulate  speech,"  and  that  both  the  inability  to  remember  words  and 
connect  them  with  ideas,  and  the  inability  to  compel  the  org  an  of  articulation 
to  form  words,  depend  upon  some  change  only  at  this  point.  Modern 
physiology  has  taught  us,  however,  that  though  the  organs  of  reception 
may  be  healthy,  there  are  certain  cortical  regions  in  relation  therewith 
which  seem  to  have  a  connection  with  the  island  of  Reil  as  well,  and 
through  recent  disease  new  perceptions  cannot  revive  the  impressions 
received  previously  in  the  healthy  state,  which  have  become  the  basis  of 
ideas,  nor  can  the  "organ  of  articulate  speech"  be  made  to  act,  though 
unaffected  itself.  The  loss  of  power  to  express  ideas  is  symptomatized  by 
aphasia,  agraphia,  or  other  defects  in  the  communicating  faculty.  If  there 
be  amnesia,  the  central  disturbance  (whatever  it  is)  is  the  same,  and  the 
variation  of  lost  means  for  expression  depends  on  the  manner  of  separa- 
tion of  organs  from  mental  control.  There  seems  to  be  little  doubt  as  to 
the  seat  of  this  centre,  and  as  to  the  circumstances  under  which  it  is  im- 
paired. The  collected  cases  of  different  authors  mainly  go  to  show  that 
the  left  side  of  the  brain  is  the  seat  of  a  lesion  in  its  anterior  part,  and 
that  the  third  frontal  convolution  is  the  one  most  constantly  involved.  I 
have  already  casually  referred  to  Broca's  investigations,  and  will  now 

^  Journal  of  Mental  Science. 


186 


DISEASES   OF    THE    CEREBRUM    AND    CEREBELLUM 


present  his  description,  which  has  been  modified  by  Bateman/  of  its  anato- 
mical seat.'  "  The  anterior  lobes  of  the  brain  comprehend  all  that  part  of 
the  hemisphere  situated  above  the  fissure  of  Sylvius,  which  separates  it 
from  the  temporo-sphenoidal  lobe  and  in  front  of  the  furrow  of  Rolando 

(R.  R.)  which  separates  it  from  the  parietal  lobe The  direction  of 

this  furrow  is  almost  transverse ;  setting  out  from  the  median  line,  it  con- 
tinues almost  in  a  direct  line,  and  after  describing  some  flexuosities  ter- 
minates below  and  outside  of  the  fissure  of  Sylvius,  which  it  meets  almost 
at  a  right  angle  behind  the  posterior  border  of  the  lobe  of  the  insula. 

"The  anterior  lobe  of  the  brain  is  composed  of  two  divisions,  the  one 
inferior,  or  orbital,  formed  by  the  sevei-al  convolutions  called  orbital,  which 
lie  on  the  roof  of  the  orbit,  and  of  which  I  shall  not  have  to  speak  ;  the 
other,  superior,  situated  under  the  outer  wall  of  the  frontal  bone,  and  under 

Fig.  26. 


the  most  anterior  portion  of  the  parietal.  This  superior  division  is  com- 
posed of  four  fundamental  convolutions  called,  properly  speaking,  the  fron- 
tal convolutions ;  one  is  posterior,  the  others  are  anterior.  The  posterior, 
FF,  slightly  tortuous  from  the  anterior  boundary  of  the  furrow  of  Rolando. 
It  is  therefore  almost  transverse,  and  ascends  from  without,  inwards,  from 
the  fissure  of  Sylvius  to  the  great  median  fissure,  which  receives  the  falx 
cerebri  of  the  brain.  This  is  why  it  (F  F)  is  described  indifferently  under 
the  n^uiQ  frontal,  j)oster lor ,  transverse,  or  ascending  convolution.  The  other 
three  convolutions  of  the  superior  division  are  very  tortuous  and  very 
complicated,  and  some  practice  is  needed  to  distinguish  them  in  all  their 
length  without  confounding  the  fundamental  furrows  which  separate  them 
with  the  secondary  furrows  which  separate  the  second  order  folds,  and 
which  vary  in  different  individuals  according  to  the  degree  of  complica- 

^  The  reader  may  also  consult  Morel's  Plate,  presented  upon  a  previous  page. 


ASEMASIA.  187 

tion ;  that  is  to  say,  according  to  the  degree  of  development  of  the  funda- 
mental convolutions.  These  three  fundamental  convolutions,  1,  2,  3,  are 
antero-posterior,  and,  running  side  by  side,  extend  from  before  backward 
over  the  whole  length  of  the  frontal  lobe.  They  commence  on  a  level  with 
the  superciliary  arch,  whence  they  are  reflected,  to  be  continuous  with  con- 
volutions of  the  inferior  division,  and  terminate  behind  in  the  frontal  trans- 
verse convolution,  F,  F,  which  all  the  three  enter.  They  are  called  first 
(1),  second  (2),  and  third  (3),  frontal  convolutions.  They  may  also  be 
called  internal  (1),  middle  (2),  and  external  (3)  ;  but  the  ordinary  names 
have  prevailed.  The  first  (1)  runs  along  the  great  fissure  of  the  brain  ; 
it  presents,  constantly,  in  the  human  species,  an  antero-posterior  furrow 
more  or  less  complete,  which  divides  it  into  two  folds  of  a  second  order ;  it 
has,  therefore,  been  divided  into  two  convolutions,  but  comparative  anato- 
my shows  that  these  two  folds  form  only  a  single  fundamental  convolu- 
tion. The  second  (2)  frontal  convolution  presents  nothing  peculiar ;  not 
so  with  the  third  ( 8),  which  is  more  external.  The  latter  presents  a  su- 
perior or  internal  border,  adjoining  the  tortuous  border  of  the  middle  con- 
volution (2),  and  an  inferior  or  exterior  border,  the  relations  of  which 
differ  according  as  they  are  examined  before  or  behind.  In  its  anterior 
half  this  border  is  in  contact  with  the  external  border  of  the  most  exter- 
nal orbital  convolution.  In  its  posterior  half,  on  the  contrary,  it  is  free 
and  separated  from  the  temporo-sphenoidal  lobe  by  the  fissure  of  Syl- 
vius, S,  S,  of  which  it  forms  the  superior  border.  It  is  in  consequence  of 
this  latter  relation  that  the  third  frontal  convolution  is  sometimes  called 
the  sujyerior  marginal  convolution. 

"  Let  me  add,  that  the  inferior  border  of  the  fissure  of  Sylvius  (S,  S) 
is  formed  by  the  superior  convolution  of  the  temporo-sphenoidal  lobe, 
which  is  therefore  called  the  inferior  marginal  convolution  T,  T.  It  is 
an  antero-posterior  fold,  thin,  and  almost  rectilinear,  which  is  separated 
from  the  temporo-sphenoidal  convolution  T  2,  T  2,  by  a  furrow  parallel 
to  the  fissure  of  Sylvius.  This  furrow  is  described  under  the  name  of  the 
^ara/(?e/ fissure  (with  reference  to  the  fissure  of  Sylvius,  S,  S).  Lastly, 
when  the  two  marginal  convolutions,  superior,  3,  3,  3,  and  inferior,  T,  T, 
are  drawn  away  from  the  fissure  of  Sylvius,  S,  S,  there  appears  an  en- 
larged and  slightly  prominent  eminence,  I,  from  the  summit  of  which 
five  small  simple  convolutions,  or  rather  five  straight  folds,  radiate  in  a 
fan-like  manner.  It  is  the  lobe  of  the  insula  which  covers  the  extra- 
ventricular  nucleus  of  the  corpus  striatum,  and  which,  arising  from  the 
bottom  of  the  fissure  of  Sylvius,  S,  S,  is  found  to  be  structurally  con- 
tinuous by  its  cortical  layer  with  the  deepest  or  most  deeply  seated  part 
of  the  two  marginal  convolutions,  3,  3,  3,  and  T,  T,  and  by  its  medullary 
layer  with  the  extra-ventricular  layer  of  the  corpus  striatum.  The  re- 
sult of  these  structural  relations  is,  that  a  lesion  which  propagates  itself 
continuously  from  the  frontal  lobe  to  the  temporo-sphenoidal  lobe,  or, 
vice  versa,  Avill  pass  almost  necessarily  by  the  lobe  of  the  insula,  and 
that  from  thence  it  will  most  probably  extend  to  the  extra-ventricular 
nucleus  of  the  corpus  striatum,  since  the  proper  substance  of  the  insula 


188        DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

I,  which  separates  the  nucleus  from  the  surface  of  the  brain,  forms  only 
a  very  thin  layer." 

Not  only  may  a  lesion  of  the  speech-centre  itself  produce  aphasia,  but 
in  numerous  instances  (some  of  which  have  been  referred  to  by  Jackson) 
it  may  follow  the  destruction  of  adjacent  parts,  as  a  consequence  of  some 
such  accident  as  the  plugging  up  of  the  middle  cerebral  artery.  As  a 
consequence  of  such  a  pathological  condition,  a  large  area  of  brain  sub- 
stance will  be  destroyed,  so  that  impaired  mental  function  as  well  as 
aphasia  takes  place.  We  shall  presently  see  that  though  this  particular 
part  of  the  third  frontal  convolution  is  the  seat  of  the  organ  of  "  speech 
expression,"  there  are  other  important  cortical  regions  which,  when  de- 
stroyed, give  rise  to  asemasia. 

An  important  subject  in  this  connection  is  the  side  of  the  brain  which 
is  affected.  Though  exceptional  cases  have  been  reported  in  which  the 
right  cerebral  hemisphere  has  been  the  seat  of  the  lesion,  the  rule  is  the 
other  way.  In  some  instances,  even,  no  lesion  whatever  has  been  found  ; 
or,  on  the  other  hand,  the  left  anterior  convolutions  have  been  the  seat 
of  morbid  change,  and  no  loss  of  speech  has  been  occasioned.  Simp- 
son ^  has  related  one  case  where  marked  destruction  of  the  left  an- 
terior lobe  was  observed,  and  yet  no  aphasia  existed.  This  man,  aged 
65,  Avho  had  been  epileptic  for  ten  years,  having  as  many  as  three  or 
four  attacks  a  month,  died.  The  white  and  gray  matter  of  the  left 
hemisphere  were  markedly  atrophied,  and  there  was  a  cavity  in  the  left 
posterior  frontal  convolution  of  H  inches  longitudinally,  and  li  trans- 
versely. 

The  following  case  is  interesting,  as  it  shows  that  almost  complete 
aphasia  may  exist  without  any  disease  of  the  island  of  Reil : — 

M.  A.  B.,  aged  thirty-five  years,  married.  Family  and  previous  per- 
sonal history  good,  but  it  is  possible  to  trace  syphilis.  The  patient  had 
an  apoplectic  attack  in  August,  1859,  with  loss  of  consciousness,  which 
lasted  for  two  hours  ;  on  recovery  it  was  .found  that  she  was  unable  to 
speak,  but  there  was  slight  improvement  after  a  few  mouths.  Present 
condition,  July  17,  1874  :  The  patient  is  a  middle-sized  woman  of  seem- 
ingly good  condition,  with  the  exception  of  her  nervous  trouble.  There 
is  slight  paralysis  of  the  left  side  ;  can  move  left  arm  well,  but  slowly, 
and  walks  with  a  shuffling  gait.  Tactile  sensibility,  and  sensibility  to 
differences  in  temperature,  are  decidedly  impaired  on  the  left  side,  on 
which  side  there  is  an  appreciable  amount  of  analgesia.  She  protrudes 
her  tongue  in  a  straight  line,  but  feebly.  No  loss  of  taste  or  smell. 
Her  mental  condition  is  below  the  average.  The  first  part  of  her  his- 
tory I  have  taken  from  the  records  of  the  Epileptic  and  Paralytic  Hospi- 
tal, and  I  also  fiad  that  for  some  months  she  has  been  suffering  from 
symptoms  of  phthisis.  When  I  saw  her  on  August  10,  187-5,  the  patient 
was  in  advanced  phthisis  ;  her  nervous  condition  was  the  following ; 
Paralysis  of  the  left  side ;  her  left  hand  lies  in  her  lap,  the  thumb  being 
contracted  and  flexed ;   the  flexor   tendons  of  the  hand   are  rigidly  con- 

1  Med.  Times  and  Gazette,  Dec  21,  1867. 


ASEMASIA.  189 

tracted,  so  that  at  the  wrists  they  stand  out  like  tense  cords.  There  is 
very  little  atrophy  of  the  left  upper  extremity,  but  there  is  a  certain  stiff- 
ness about  the  elbow-joints  of  this  side.  The  left  lower  extremity  seems 
to  be  nearly  as  strong  as  its  fellow.  Motion  at  the  hip  and  knee-joiuts  is 
limited.  She  can  raise  her  foot  from  the  ground  when  sitting,  but  when 
she  walks  it  is  in  a  shambling  manner,  dragging  her  left  foot,  or  scarcely 
lifting  it  from  the  ground.  There  is  some  paralysis  of  the  left  side  of 
the  face,  and  it  is  impossible  for  her  to  protrude  her  tongue.  Sensibility 
seems  to  be  very  slightly  aifected  in  the  paralyzed  side.  She  is  almost 
completely  aphasic,  her  repertoire  of  words  being  confined  to  "  yes  "  and 
"  no,"  the  former  being  repeated  several  times  in  answer  to  any  ques- 
tions she  may  be  asked.  When  she  is  asked  her  name,  she  is  unable  to 
tell  it.  "  Is  it  Jane  ?"  she  shakes  her  head  and  smiles.  "  Is  it  Ann  ?  ' 
another  shake  of  the  head,  and  an  attempt  to  speak,  the  only  result  being 
the   production  of  an  unintelligible   noise.     "  Is   it   Mary  ?"  when   she 

brightens   up   and  says,  "  Yes,  yes,   yes ;   Ma "  prolonged,   and   she 

generally  gives  it  up  in  disgust.  She  cannot  write,  but  makes  a  disor- 
derly scrawl ;  although  we  learn  from  her  friends  that  in  health  she  wrote 
well.  She  gesticulates  a  good  deal,  and  endeavors  to  attract  the  atten- 
tion of  those  in  the  ward,  and  evidently  appreciates  everything  that 
goes  on  about  her.  Her  pupils  are  easily  dilated,  but  she  does  not  see 
with  the  right  eye,  and  on  examination  I  find  atrophy  of  the  optic  disk. 
During  the  winter  and  spring  of  1875-76,  she  seemed  to  sufier  much  from 
her  pulmonary  trouble.  There  was  oedema  of  the  lower  extremities,  which 
increased  so  that  the  anasarca  became  general,  but  she  was  somewhat 
relieved  by  digitalis  and  iron  ;  diarrhoea  supervened,  and  she  finally  died 
on  the  second  day  of  June,  1876. 

Autopsy. — The  dura  mater  was  considerably  thickened,  and  presented 
the  appearance  of  old  pachymeningitis.  There  was  no  lesion  to  be  dis- 
covered in  either  third  frontal  convolution,  but  an  old  clot  was  found  in 
the  right  caudate  nucleus.  This  clot  was  about  half  an  inch  in  diameter, 
and  was  surrounded  by  some  dense  tissue.  Cortical  lesions  were  present 
on  both  sides  of  the  brain,  but  of  superficial  extent,  and  confined  chiefly 
to  the  parietal  convolutions ;  these  consisted  of  softened  patches  in  ad- 
vanced stages  of  degeneration.  The  cerebral  arteries  contained  patches 
of  a  yellowish  or  atheromatous  nature.  The  spinal  cord  was  not  exam- 
ined. Both  lungs  were  found  to  be  tubercular,  and  in  the  middle  lobe  of 
the  right  there  was  a  large  cavity.  I  was  unable  to  find  any  tubercular 
deposit  whatever  in  the  brain  or  its  meninges.  The  left  frontal  convolu- 
tions were  examined,  but  no  disease  whatever  was  found,  and  the  occipital 
convolutions  were  in  normal  condition. 

Hemingway  reports  the  following  interesting  case  of  left-sided  paralysis 
with  aphasia :  ^ 

Jane  R.,  aged  30,  widow ;  occupation  seamstress ;  education  fair,  can 
read  and  write.  Entered  hospital  October  30,  1873.  Family  history 
good  ;  says  she  always  was  a  healthy  woman  till  present  illness.  Admits 
having  had  a  sore  on  genitals  five  years  ago.  Cicatrices  are  at  present 
visible  on  forehead,  which  are  probably  a  result  of  tubercular  syphilides ; 

1  Medical  Record,  March  4,  1876. 


190        DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

says  they  came  there  five  years  ago.  Her  left  eye  shows  the  result  of  an 
old  ophthalmia,  which,  it  was  supposed,  was  of  gonorrhoeal  origin.  For 
two  years  past  has  had  slight  palpitations  on  exertion.  Always  used  her 
right  hand  in  her  occupation.  Four  months  ago,  one  night  when  she  was 
going  to  bed  she  became  suddenly  speechless ;  there  was  no  paralysis 
whatever.  Next  morning,  on  attempting  to  arise,  found  her  left  arm,  leg, 
and  side  of  face  paralyzed  ;.  also,  with  loss  of  sensation  in  those  parts. 
Loss  of  speech  was  complete  ;  and  hearing,  which  before  this  was  excel- 
lent, was  now  lost  in  left  ear.  Her  tongue  was  only  affected  in  sensation ; 
she  was  not  able  to  appreciate  sweet  substances  placed  on  the  tongue ; 
sense  of  smell  also  lost.  About  one  month  after  this  attack,  i.  e.,  three 
months  ago,  improvement  began  in  speech,  face,  and  lower  extremity, 
and  has  continued  since  then.  Upper  extremity  began  to  improve  one 
month  ago.  Sphincters  have  not  been  affected.  Is  a  medium-sized  wo- 
man, pretty  well  nourished ;  mental  faculties  good,  with  exception  of  loss 
of  memory,  constituting  well-marked  amnesic  aphasia.  Is  unable  to  re- 
collect many  words,  names  of  objects,  as  hat,  key,  handkerchief,  pencil, 
etc. ;  though  she  can  readily  repeat  them  on  being  told,  she  forgets  them 
immediately  afterwards.  Is  unable  to  read  continuously,  omitting  words, 
and  giving  up  from  inability  to  fix  attention.  On  attempting  to  write 
the  letters  of  the  alphabet,  the  result  was  ABCDSGHI;  but  when 
the  letters  were  separately  told  her,  she  wrote  them  down  easily.  Partial 
paralysis  remains  on  left  side  of  face  ;  cannot  close  eyelids  tightly.  Sen- 
sation is  lost  to  a  great  extent  on  left  side  of  face,  and  in  left  nostril. 
Does  not  wince  on  the  application  of  aqua  ammonia  to  left  nostril,  nor 
when  the  conjunctiva  on  same  side  is  touched  with  an  irritant.  Hearing 
poor  on  left  side.  Taste  is  impaired  anteriorly  and  posteriorly  on  left 
side  of  tongue. 


Dynamometer,     -j        .  j",    oa'      r      outer  circle. 


^sthesiometer  is  valueless,  on  account  of  loss  of  sensation,  of  reaction 
to  pain.  Does  not  wince  on  pinching  arm,  but  does  on  palm  of  hand  and 
tips  of  fingers.  Perception  delayed ;  takes  about  three  seconds.  Can 
raise  arm  to  level  of  shoulder,  a  little  stiffly.  Can  flex  and  extend  fore- 
arm and  fingers,  but  slowly.  Heart  sounds  normal.  Walks  without  elas- 
ticity. Sensation  in  leg  as  in  arm.  Reflex  action  lessened.  Electro- 
muscular  contractility  good. 

The  accumulation  of  reported  cases,  however,  in  which  the  lesion  was 
on  the  left  side,  leaves  no  doubt  in  regard  to  this  question.  Jackson  and 
Ramskill  report  40  cases  of  right  hemiplegia  with  aphasia,  and  but  one  of 
left  hemiplegia.  Ogle^  reports  25  cases  all  with  the  lesion  in  the  left 
hemisphere,  though  there  were  morbid  changes  in  some  of  these  in  other 
parts.  In  not  one  of  these  where  the  lesion  was  on  the  left  side  was 
there  undisturbed  speech.  Magnan^  reported  thirty-one  cases  of  aphasia, 
and  in  all  but  four  was  there  right-sided  hemiplegia.  Trousseau,  in  1868, 
had  collected  all  the  cases  he  could  find,  the  number  being  over  one 
hundred,  and  in  all  but  ten  there  was  right-sided  paralysis.    Seguin^  has 

*  St.  Geo.  Hosp.  Reports,  vol.  ii. 

^Bull.  de  I'Academie  de  M^decine. 

'  Quarterly  Journal  of  P.sychological  Medicine,  1861,  xxx.,  663. 


ASEMASIA.  191 

collected  46  cases  from  the  records  of  the  New  York  Hospital,  and  in  all " 
but  three  there  was  right  hemiplegia.     Thus  it  is  settled,  I  think,  that 
the  left  side  of  the  brain  is  that  which  contains  the  speech-centre. 

The  question  as  to  the  relative  frequency  of  right  and  left  hemiplegia 
naturally  arises,  and  from  the  inspection  of  a  large  number  of  cases  it  will 
be  seen  that  there  is  a  very  slight  preponderance  of  the  former. 

Browne,^  from  Baillarger's  tables,  says  that  "  in  aphasia  right  is  to  left 
hemiplegia  as  15  is  to  1." 

By  the  following  table  it  will  be  seen  that  there  is  very  slight  prepon- 
derance of  right-sided  paralysis,  and  the  comparison  between  the  infre- 
quency  of  aphasia  with  left  hemiplegia,  and  the  slight  difference  between 
the  relative  frequency  of  occurrence  of  both  forms,  is  inconsiderable. 

Cases  of  hemiplegia.      K.  L. 

Ogle 75  43  32 

Andral 136  73  63 

Baillarger 110  58  52 

321  174  147 

As  to  the  exact  site,  Seguin  tabulates  545  cases,  in  all  of  which  but  31 
the  lesion  was  in  the  left  anterior  lobe.  Why  the  left  side  is  the  seat, 
especially  when  embolism  or  thrombosis  is  the  cause,  has  already  been 
explained  by  the  fact  that  the  left  middle  cerebral  artery  is  that  which 
is  in  the  most  direct  line  from  the  heart.  The  next  link  in  the  chain, 
which  is  the  question  of  valvular  disease,  and  its  connection  with  loss  of 
speech,  has  been  discovered  by  H.  Jackson,  who  has  found  that  valvular 
disease  is  nearly  always  associated  with  the  hemiplegia,  that  is,  connected 
with  loss  of  speech.     He  has  seen  more  than  50  of  these  cases. 

The  records  of  cases  of  right  hemiplegia  with  aphasia  in  which  I 
made  autopsies,  show  that  there  were  other  lesions,  but  always  some 
trouble  in  the  course  of  the  middle  cerebral  artery.  I  therefore 
agree  fully  with  the  majority  of  observers,  that  loss  of  speech  de- 
pends, except  in  rare  instances,  upon  lesions  in  the  left  hemisphere,  but 
that  it  may  also  follow  a  lesion  in  the  other  hemisphere.  Both  Brown- 
Sequard  and  Van  der  Kolk  hav-e  advanced  theories — the  first,  that  articu- 
late speech  is  a  reflex  process ;  and  the  latter,  that  it  is  seated  in  the  oli- 
vary bodies.  This  last  view  was  held  by  Willis,  Solly,  and  others.  Lay- 
cock  is  of  opinion  that  these  organs  are  "  subservient  to  the  emotions 
through  the  muscles  of  the  face  and  tongue  by  language,  and  emotional 
cries  and  sounds."  And  he  says :  "  It  is  by  no  means  improbable,  how- 
ever, that  the  emotional  movements  of  the  hands,  as  well  as  of  the  tongue 
and  face,  are  likewise  under  their  direction.  They  are,  therefore,  to  be 
considered  as  regulative  ganglia  to  the  motor  centres  of  the  facial,  hypo- 
glossal, and  limb  nerves  in  the  medulla  oblongata  belonging  to  the  sub- 
strata of  the  sensory  tract." 

Dr.   Herbert  Major, ^  in   a   very  complete   article   upon   the   micro- 

1  W.  Eiding  Eeports,  vol.  ii.,  p.  284. 
*  West  Eliding  Eeports,  vol.  vi.  1. 


192        DISEASES     OF    THE    CEREBRUM    AND    CEREBELLUM. 

scopical  anatomy  of  the  island  of  Reil,  sums  up  his  conclusions  as 
follows  : — 

"  1.  The  cortical  layers  of  the  insula  agree  in  number,  order,  and  gen- 
eral arrangement  with  those  of  the  vertex,  but  the  cells  of  the  third  layer 
are  in  the  insula  generally  smaller  than  at  the  vertex.  The  vessels  and 
neuroglia  present  no  peculiarity. 

"  2.  The  various  gyri  forming  the  insula  present  a  similar  structure. 

"  'it.  No  difference  of  structure  can  be  detected  in  the  right  as  com- 
pared with  the  left  insula. 

"  4.  The  method  of  union  of  the  white  matter  with  the  cortex  is  in  the 
insula  similar  to  that  observed  in  other  lobes." 

The  departure  from  the  healthy  state  is  seen  in  enlarged  vessels,  a 
shrunken  appearance  of  the  cells  of  the  first  layer  and  a  diminution  in 
their  number,  together  with  even  a  change  in  the  cell-contents,  the  nuclei 
being  broken  down  and  agglomerated  at  the  centre.  The  cells  of  the 
second  and  third  layers  have  lost  their  processes,  and  the  protoplasm  con- 
tains granular  debris,  while  the  other  cells  of  the  lowermost  layers  suffer 
the  same  changes  as  well  as  transposition. 

Aphasia  may  be  dependent  upon  any  form  of  brain  disease  which  pro- 
duces disorganization  of,  or  pressure  upon,  the  third  frontal  convolution 
or  parts  immediately  adjacent  or  of  certain  cortical  centers  behind  the 
fissure  of  Rolando.^  Among  the  common  diseases  which  lead  to  the 
structural  changes  are  cerebral  hemorrhage,  thrombosis  or  embolism, 
tumor,  or  sclerosis,  as  well  as  certain  forms  of  meningitis.  Age  appears 
to  play  but  a  small  part  in  the  production  of  this  condition,  except  so  far 
as  it  influences  cerebral  hemorrhage,  embolism,  or  the  other  diseases  just 
mentioned. 

Since  the  appearance  of  the  first  edition  of  this  book  the  study  of 
aphasia  has  received  fresh  impetus  as  a  result  of  the  development  of 
our  knowledge  of  cerebral  localization.  The  observations  of  Munk"  have 
materially  altered  the  views  of  physiologists,  and  the  recent  writings  of 
Kussmaul,  Bastian,  Broadbent  and  others,  have  established  the  existence 
of  the  cerebral  cortical  centers,  which  play  a  part  in  asemasia  and  one  of 
great  importance. 

Bastian^  has  formulated  the  ideas  of  modern  writers  as  follows  : — 

I.  Defects  of  verbal  memory;  that  is  defects  in  the  association  of  ideal 
things  or  of  conceptions  with  ideal  words. 


^  Among  fift€en  cases  reported  by  Sander*  there  were  two  in  which  the  original 
lesion  was  found  in  the  left  parietal  lobe,  in  some  of  the  bundles  of  fibres  radiating 
from  the  corpus  striatum. 

''  Ueber  die  Functionen  der  Gehirnsrinde. 

■^  The  Brain  as  an  organ  of  Mind,  1880. 


*  Archiv  fiir  Psychiatric,  ii.  38. 


ASEMASIA.  193 

A.   AMNESIA   VERBALE. 

(a.  Paralytic  variety ;  b.  Incoordinate  variety.) 

1.  Diminished  Excitability  of  the  Auditory  Word-Centres. 

2.  Defective  Action  of  the  Visual  Word-Centres. 

3.  Damage  to  Visual  Word- Centres  and  of  Afferent  Fibers  to  Auditory 
Centres ;  together  with  certain  defects  producing  Incoordinate  Amnesia. 

4.  Damage  to  commissures  between  Auditory  and  Visual  Word-Centres. 
II.  Defects  in  the  association  of  Ideal  Words  with  verbal  movements 

for  speech  and  writing,  or  for  either  of  them  singly. 

JB.    APHASIA. 

5.  Damage  to  first  parts  of  outgoing  tracts  leading  from  Cerebral 
Word-Centres  to  left  Corpus  Striatum. 

C.  AGRAPHIA. 

6.  Damage  to  first  parts  of  outgoing  tracts  leading  from  the  left  Visual 

Word-Centre. 

D.  APHEMIA. 

7.  Damage  (a)  to  first  parts  of  outgoing  tract  leading  from  the  left 
Auditory  Word-centre,  or  (b)  to  some  lower  part  of  the  same  tract,  or 
(c)  to  the  actual  Motor  Centres  for  articulation. 

The  involvement  of  the  visual  and  auditory  centres  as  has  been  stated, 
even  though  there  may  be  no  disease  of  the  island  of  Reil,  accounts  for 
the  production  of  the  various  forms  of  asemasia.  In  well  reported  recent 
cases  the  matter  has  been  definitely  settled  that  destruction  of  one  or 
both  of  these  centres,  may  be  followed  by  disruption  of  the  corrective  in- 
fluence of  visual  or  auditory  associations.  The  individual  maybe  unable 
to  speak  or  write  upon  dictation,  or  he  may  be  equally  powerless  to 
copy  a  printed  page  or  correctly  count  a  given  number  of  objects  or 
figures.  The  case  of  the  late  Dr.  Allin,  of  New  York,  which  has  been 
ably  reported  by  Dr.  A.  B.  Ball,  is  one  of  the  most  valuable  contribu- 
tions to  the  modern  literature  of  aphasia.  In  Dr.  Allin's  case  the  lesion 
was  confined  to  the  "  whole  of  the  inferior  parietal  lobule  and  the  first 
temporal  gyri,"  and  no  change  in  the  Island  of  Reil  was  found.  Dr. 
Allin  visited  my  office  some  months  before  his  death,  and  at  various 
times  had^been  seen  by  Drs.  Ball,  Seguin  and  Metcalfe. 

The  feature  of  his  asemasia,  was  his  inability  to  use  common  nouns  and 
proper  names.  He  was  able  usually  to  closely  approach  in  sound  the 
word  he  desired  to  use,  but  if  he  saw  the  initial  or  heard  the  first  syllable, 
he  was  able  to  finish  the  rest.  At  first  he  was  unable  to  repeat  the  word 
after  it  had  been  pronounced  by  another  person,  but  subsequently  learned  a 
large  number  of  words  used  in  ordinary  conversation.  He  was  agraphie , 
and  could  not  write  at  dictation  though  he  recognized  the  number  of 
letters  and  made  them  by  straight  lines.  He  was  utterly  unable  to  com- 
prehend auditory  symbols.  Dr.  Ball  said  to  him,  "  Dr.  Peters  called  to 
see  you;"  he  replied,  "I  don't  know  him."  The  name  was  repeated  to 
13 


194        DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

him  several  times,  but  he  failed  to  recognize  it,  although  it  was  the  name 
of  an  intimate  friend.  The  written  name  was  then  shown  him  ;  "  What  a 
fool  I  am,"  he  exclaimed,  "  of  course  I  know  him."  He  afterwards  said, 
"  The  words  I  can't  pronounce  are  the  words  I  can't  hear."  This  indi- 
cated a  disruption  of  the  auditory  control.  Dr.  AUin  could  sing,  gesticu- 
late, but  manifested  a  peculiar  symptom — the  reversal  of  the  position  of 
objects  he  took  up.  For  example,  he  placed  his  knife  and  fork  with 
their  points  toward  him  upon  the  table,  but  he  immediately  recognized 
his  mistake.  When  he  read  aloud  he  seemed  to  have  lost  the  guiding 
control  of  the  ear,  for  he  often  used  the  wrong  word. 

The  failure  of  the  visual  and  auditory  centres  gives  rise  to  many  inter- 
esting phases  of  hindered  speech  action  and  writing  power.  Bastian  il- 
lustrates the  table  I  have  just  given  by  several  groups  of  cases  of  which 
the  following  are  examples  : — 

1.  An  individual  who  could  articulate  distinctly  any  words  that 
occurred  to  him  either  spontaneously  or  when  they  were  pronounced 
slowly  and  loudly,  but  could  not  speak  at  other  times.  He  could  read 
aloud  from  printed  copy,  but  could  not  repeat  the  words  he  had  seen  the 
moment  before.  Here  was  a  case  in  which  the  auditory  centre  was  needed 
and  when  words  were  not  properly  revived  by  volitional  excitation. 

2.  An  individual  who  could  repeat  spoken  words  but  could  not  read 
aloud. 

3.  Dr.  Banks'  case  of  the  man  who  had  lost  the  power  of  apprehend- 
ing what  was  spoken  by  others  with  loss  of  comprehension  of  written  or 
printed  characters. 

The  explanation  of  word  blindness  recently  given  by  Magnan^  bears 
out  the  investigation  of  Ferrier  and  Tamburini.  Magnan  considers  that 
there  are  two  centers  which  are  involved ;  the  visual  perception  goes 
first  to  the  corpora  geniculata  or  some  other  center  in  their  neighborhood 
(see  Charcot's  plate,)  and  from  them  to  the  angular  gyrus,  where  it  is 
made  the  basis  of  psychic  action  involving  an  exercise  of  memory  and 
reasoning  power.  The  disruption  of  this  center  with  the  island  of  Reil, 
eventuates  in  the  phenomenon  of  word  blindness,  as  the  idea  cannot  form 
expression.     Two  cases  have  been  presented  by  him. 

Very  few  examples  of  aphasia  in  very  young  persons  have  been  re- 
ported, for  vascular  neuroses  are  quite  unusual  among  children,  and  right 
hemiplegia,  with  a  lesion  in  this  particular  part  of  the  brain,  is  of  rare 
occurrence.  A  case  was  reported  by  Eulenburg  which  was  quite  unique.' 
The  patient  was  eight  years  old ;  two  years  before  he  had  had  scarlet 
fever,  and  six  weeks  after  the  development  of  the  disease  there  were  con- 
vulsions and  coma,  followed  by  right  hemiplegia  with  aphasia.  The  pa- 
ralysis almost  subsided  in  two  weeks.  He  speaks  but  two  words,  viz  : 
"  Ach,"  which  he  always  uses  for  "  mien,"  and  "  Ja,"  with  which  he  an- 
swers all  other  questions.     The  fact  that  dropsy  and  albuminuria  had  ex- 


1  Gazette  des  H6pitaux,  Jan.  24,  1880. 
*  Berlin  Med.  Gesellschaft,  July,  1869, 


ASEMASIA.  195 

isted  induced  the  author  to  infer  the  presence  of  softening  of  the  central 
organ  of  speech. 

Aphasia  of  a  temporary  character  may  depend  upon  functional  condi- 
tions, such  as  cerebral  congestion,  indigestion,  or  as  the  result  of  fright 
or  other  emotional  forms  of  excitement,  or  may  be  connected  with  epilepsy 
or  hysteria.  Kasch^  reports  three  cases  of  transitory  aphasia  due  un- 
doubtedly to  cerebral  congestion.  One  of  these  was  a  very  stout  woman 
who,  having  drank  a  very  large  quantity  of  carbonic  acid  water,  fell  to 
the  floor  after  being  dizzy,  but  did  not  lose  consciousness.  This  seizure 
was  followed  by  headache,  and  later  by  complete  aphasia.  She  subse- 
quently recovered.  Two  cases  of  aphasia  of  a  similar  character  are  re- 
ported by  Berger.' 

Habershon  ^  presents  an  example  of  aphasia  which  was  caused  by  fright. 
A  much  more  rare  variety  of  the  disease  is  that  which  is  connected  with 
epilepsy.  Three  such  cases  were  published  by  Allbutt.*  One  of  these 
patients  fell,  striking  on  his  left  temple ;  some  time  afterwards  epilepti- 
form attacks  appeared  with  paralysis  of  the  right  arm  and  leg.  The 
second  case  was  that  of  a  woman  aged  fifty,  who  had  had  epileptic  con- 
vulsions of  a  bilateral  character  for  two  years.  After  the  attack  she  was 
somewhat  aphasic,  and  "  had  a  mental  vision  of  the  words,"  but  was  un- 
able to  speak  them.  This  condition  of  affairs  lasted  for  two  hours.  The 
third  patient  was  a  man,  thirty  years  of  age ;  there  was  no  loss  of  con- 
sciousness, but  attacks  of  hypersesthesia  in  the  right  arm  and  hand,  fol- 
lowed by  blindness,  lasted. for  twenty  minutes  or  longer,  and  were  suc- 
ceeded by  speechlessness  lasting  two  hours. 

Diagnosis. — In  making  the  distinction  between  aphasia  and  other 
difficulties  of  spsech,  we  are  apt  to  be  misled  by  defects  in  articulation, 
dependent  upon  inco-ordination  or  paralysis  of  the  tongue,  or  by  certain 
mental  irregularities,  or  sometimes  by  congenital  mutism.^  We  are  to  bear 
in  mind  the  fact,  that  there  may  be  transitory  aphasia,  but  that  organic 
disease  of  the  speech-centre  is  generally  of  permanent  duration  ;  and  that 
there  are  but  very  few  exceptions  to  this  rule.  The  speech  defects  which 
are  of  a  local  character  are  symptomatized  by  the  patient's  inability  to 
speak  at  all,  though  he  may  fully  convince  us  of  his  ability  to  form  words 
and  appreciate  their  meaning ;  and,  moreover,  he  can  always,  should  there 

1  Berliner  Klin.  Wochenschrift,  1869,  433. 

2  Wien.  Med.  Woch.,  1869,  102. 

*  London  Lancet,  1870;  vol.  ii.  402. 

*  Med.  Times  and  Gazette,  1869,  vol.  i.  p.  491. 

5  Dr.  Browne,*  of  the  West  Eiding  Asylum,  recently  examined  29  cases  of  morbid 
affections  of  language,  or  all  in  the  existing  population  of  the  Crichton  Institution 
at  Dumfries ;  14  of  these  were  females,  and  15  males.  Of  these,  which  he  arranged 
in  three  classes,  he  found  among  the  women :  "  1.  Intermittent  mutism  5,  in  one  con- 
nected with  the  catamenia.  2.  Constant  mutism,  7 :  of  these  one  had  been  a  public 
singer ;    1  when  roused  could  with  difficulty  articulate,  having  facial  paralysis ;   1 

*  Op.  cit.  p.  297. 


196         DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

not  be  paralysis  of  the  hand  or  forearm,  write  any  word  that  he  may  wish 
to  speak.     This  is  not  the  case  in  aphasia.     In  lighter  forms  of  tongue 
paralysis  there  is  no  trouble  about  the  selection  of  words,  but  simply  a 
clumsiness  in  pronounciation,  and  in  many  of  these  forms  evidences  of 
local  muscular  weakness,  in  connection  with  the  speaking  apparatus,  draw 
attention  to  the  real  nature  of  the  trouble.     A  disease  presenting  these 
local  defects  is  a  so-called  glosso-pharyngeal  paralysis.     The  same  condi- 
tion of  affairs  is  met  with  in  general  paralysis  of  the  insane,  but  with  this, 
as  well  as  other  troubles  of  the  same  kind,  there  are  various  other  symp- 
toms which  accompany  the  speech  defect,  such  as  mental  impairment, 
with  peculiar  delusions  and  muscular  trembling.     Hysteria  sometimes 
o-ives  rise  to  a  very  curious  speech  derangement,  which,  in  its  strictest 
sense,  can  hardly  be  called  aphasia.     The  patient  occasionally  introduces 
obscene  and  profane  words  in  place  of  others  more  conventional.    A  form 
of  speech  trouble  described  by  Winslow'  and  Romberg'  is  expressed  by 
mimicry  of  individuals,  who  speak  to  the  patient  or  who  talk  within  ear- 
shot.    He  closely  imitates  the  tones  of  their  voices  and  mannerisms,  and 
repeats  the  words  addressed  to  him,  besides  mimicking  their  gestures  and 
attitudes.     These  phenomena  are  occasionally  seen  among  the  insane. 
Romberg  has  called  this  morbid  state  echolalla.     I  have  at  present  a  case 
under  observation  who  is  an  example  of  this  kind,  only  his  infirmity  does 
not  exist  to  so  marked  a  degree  as  in  the  cases  of  the  two  observers  above 
mentioned.     My  patient  is  an  idiot,  and  possesses  but  very  little  mental 
power.     He  can  point  to  his  mouth,  places  his  hand  upon  his  abdomen 
when  hungry,  and  can  call  attention  to  his  bodily  needs  by  equally  simple 
gestures,  but  beyond  this  he  is  more  an  automaton  than  a  living  being. 
When  asked  a  question,  for  instance,  "How  are  you?"  he  repeats  the 
two  last  words,  "  Are  you?"  and  "  Why  don't  you  answer?  "  he  replies, 
"Don't  you  answer?"    He  invariably  repeats  the  last  two  or  three  words 


could  not  walk  in  consequence  of  spinal  deformity  ;  1  was  an  idiot  laboring  under 
phthisis;  1  uttered  cries  when  suffering  pain.  3.  One  was  reduced  to  monosyllabic 
utterances.     4.  One  manifested  incessantly,  day  and  night,  irresistible  loquacity. 

Among  the  males:  "Intermittent  mutism,  1.  2.  Constant  mutism,  5:  in  1  the 
mutism  is  of  20  years'  duration  ;  in  1  it  is  accompanied  by  tremor  of  the  limbs  ;  in  a 
third,  who  attempted  to  cut  his  throat,  there  is  unintelligible  muttering  soliloquy.^  3. 
One  was  reduced  to  monosyllabic  utterances.  4.  Two  manifested  constant  loquacity : 
in  one,  an  idiot,  there  is  congenital  left  hemiplegia  ;  in  the  other,  who  is  healthy,  the 
loquacity  is  so  great  and  rapid  that  the  words  run  into  each  other  so  that  he  seems  to 
speak  in  long  sentences.  5.  Two  present  symptoms  of  general  paralysis  ;  the  articu- 
lation is  indistinct  or  unintelligible.  6.  In  one  case  there  appeared  to  be  the  omis- 
sion of  the  first  syllable  of  every  word,  followed  by  alternate  mutism  and  loquacity. 
7.  In  one,  an  idiot,  language  is  limited  to  a  few  words,  and  these  are  exclusively 
oaths,  with  congenital  right  hemiplegia,  and  club-foot.  8.  Two  idiots  emit  nothing 
but  acute  inarticulate  cries  ;  one  roars  like  a  wild  beast."  There  was  no  paralysis  in 
these  cases  except  of  the  face  in  two  general  paralytics,  and  of  the  lower  extremities 
in  two  idiots,  the  paralysis  in  these  latter  cases  being  congenital. 

1  Obscure  Diseases  of  the  Brain  and  Mind,  Am.  ed.  p.  343. 

2  A  Manual  of  the  Nervous  Diseases  of  Man,  Syd.  Trans.,  vol.  ii.  p.  431. 


A8EMASIA.  197 

of  any  question  that  may  be  put  to  him,  so  that  his  answers  are  but  echoes 
of  the  questions.  Such  a  defect  is  explained  by  Bastian  by  the  fact  that 
"the  auditory  word  centres  respond  only  to  direct  'sensory'  incitations, 
and  not  at  all  to  those  of  the  '  associational '  or  'volitional'  types." 

In  the  early  speech  disturbances  of  left  hemiplegia,  or  organic  diseases 
of  the  brain,  the  patient's  attempts  to  articulate  will  result  in  a  clumsy 
and  mispronounced  word ;  while  in.  aphasia  his  articulation,  be  it  ever  so 
limited,  is  rarely  imperfect,  his  "  yes  "  or  "  no  "  being  fairly  pronounced, 
or,  if  he  has  improved  so  far  as  to  be  able  to  pronounce  but  a  part  of  a 
word,  he  will  do  this  distinctly,  while  perhaps  the  other  syllables  will 
either  be  not  pronounced  at  all,  or  in  such  a  way  as  to  be  utterly  unintel- 
ligible. There  are  generally  with  the  aphasic  great  impatience  and  em- 
barrassment, mimicry,  and  gesticulation,  which  are  evidences  of  mortifi- 
cation arising  from  the  knowledge  of  his  failing,  and  his  gestures  take 
the  place  of  words.  In  agraphia  the  handwriting  or  results  of  attempts 
at  writing  must  be  compared  with  specimeas,  such  as  would  be  made  by 
patients  who  are  insane,  ataxic,  or  paralyzed,  and  it  is  necessary  for  us  to 
carefully  note  the  omission  of  words,  or  combination  of  syllables  which 
bear  no  relation  to  one  another,  as  well  as  the  character  of  the  patient's 
composition.  If  he  be  insane,  he  will  not  admit  any  absurdities  to  which 
he  may  give  expression,  but  with  the  aphasic  the  case  is  different,  for  he 
always  evinces  his  chagrin  when  he  finds  that  he  has  written  the  wrong 
word,  and  endeavors  to  correct  his  mistakes.  There  are  cases  spoken  of 
by  Bacon  ^  and  others,  in  which  the  only  evidence  of  the  patient's  insanity 
is  his  writing,  but  even  here  the  defect  is  more  in  the  expression  of  a  dis- 
ordered mental  state  than  in  an  impairment  of  the  communicating  faculty. 
The  handwriting  of  the  general  paralytic  sometimes  closely  resembles 
that  of  the  aphasic  patient,  but  in  the  first,  with  time  there  is  progressive 
impairment,  while  in  the  other,  if  anything,  there  is  improvement. 

The  medico-legal  questions  which  may  arise  in  regard  to  the  responsi- 
bility of  aphasia  are  worthy  of  consideration.  The  aphasic  of  course 
may  suffer  an  intellectual  impairment,  which  lasts  a  short  time  after  the 
attack.  This  is  not  necessarily  accompanied  by  a  loss  of  judgment.  It 
is  more  a  condition  of  mental  sluggishness,  and  it  will  not  do  to  say  that 
the  individual  is  incompetent.  The  aphasic  makes  intelligent  efforts  to 
communicate,  even  though  he  may  not  be  able  to  do  so.  He  gesticulates, 
and  tries  to  explain  himself,  and  the  expression  even  of  his  eyes  tells  of 
everything  but  intellectual  unsoundness.  Additional  evidence  of  soften- 
ing in  dementia  throws  an  entirely  different  light  upon  the  matter,  but 
even  then  it  must  be  remembered  that  aphasia  is  not  necessarily  associated 
with  such  states. 

A  case  of  interest  is  reported  by  M.  Lucas  Championnieres  :  ^  "  The 
question  was  raised  in  this  particular  instance  a  propos  of  a  case  in 
which  the  patient,  in  spite  of  an  enfeebled  intelligence,  had  become  ca- 

1  On  the  Writing  of  the  Insane,  p.  12. 

2  .Journal  de  Med.  et  de  Chir.  Prat.,  abst.  Br.  Med.  Journ.  Sept.  15,  1877. 


198         DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

pable  of  writing  with  the  other  hand.  He  could  not,  however,  write  if 
left  to  himself,  and  could  only  recopy  what  was  written  and  set  before 
him,  and  the  expert  physicians  vainly  tried  to  make  him  recopy  a  power- 
of  attorney  or  a  will,  while  he  willingly  wrote  any  ordinary  phrase  or 
document  which  did  not  bind  him  to  anything.  This  man,  then,  knew 
perfectly  what  he  was  doing,  and  the  Societe  de  Medecine  Legale  con- 
cluded that  he  possessed  still  thorough  intelligence  and  free  will  to  be 
able  to  continue  to  enjoy  his  civil  rights,  the  intellectual  debility  which 
he  had  suffered  not  appearing  to  be  sufficient  to  justify  what  the 
French  laws  call  an  'interdiction.'"  The  society  recommended  that 
he  should  be  taken  care  of  by  a  "  council,"  so  that  he  should  be  guar- 
anteed protection  against  danger  that  might  arise  in  the  condition  of  his 
affairs. 

We  must  bear  in  mind  the  existence  of  heart  trouble  should  it  exist, 
or  vegetations  and  other  indications  of  extraneous  disease  which  might 
lead  to  the  causation  of  thrombosis  or  embolism. 

In  regard  to  the  diagnosis  of  aphasia  it  may  be  said  upon  the  autho- 
rity of  Seguin  that  "  predominant  word  deafness  or  word  blindness,  with 
hemiansesthesia,  cutaneous,  muscular  or  sensorial,  is  dependent  upon  a 
lesion  placed  behind  the  fissure  of  Rolando  in  regions  which  correspond 
with  the  sensory  cortical  centres." 

Prognosis. — The  view  we  are  to  take  of  our  patient's  condition  is  to 
be  governed  entirely  by  the  question  whether  there  is  or  not  a  primary 
organic  disease,  its  importance  and  the  character  of  the  aphasia.'  In 
the  light  forms,  such  as  result  from  fright  and  cerebral  congestion,  or 
those  connected  with  hysteria,  the  proguosis  is  exceedingly  good,  and  the 
same  is  the  case  when  it  is  the  result  of  protracted  fever.  Legroux 
(op.  cit.  p.  60)  speaks  of  an  aphasia  of  quite  temporary  duration,  which 
is  occasionally  of  gouty  origin,  or  connected  with  diabetes  or 
albuminuria.  ^  Dr.  Rotch  has  also  described  varieties  of  tempory  aphasia 
met  with  in  patients  who  are  the  subjects  of  Bright's  disease,  and  presents 
two  cases.  The  prognosis  of  the  condition  itself  is  quite  good,  but  a 
serious  indication  of  grave  cerebral  trouble.  Aphasia  with  paralysis  is 
always  significant  of  deep  trouble.  Such  an  aphasia,  when  it  occurs 
with  hemiplegia,  may  persist  perhaps  during  the  individual's  lifetime, 
and  after  every  vestige  of  the  hemiplegia  has  disappeared.  If  there 
be  softening,  or  previous  acute  cerebral  disease,  or  if  there  be  evidence 
of  arterial  degeneration,  or  valvular  deposits,  the  case  assumes  a  hope- 
less aspect,  and  may  be  nearly  always  pronounced  incurable.  Aphasia 
as  the  result  of  traumatism  is  occasionally  relieved  by  surgical  interfer- 
ence. 


^  In  one  case  reported  by  Bateraan,  the  patient  recovered  almost  entirely,  and  he 
could  pronounce  every  word  distinctly,  with  the  exception  of  those  containing  the 
letter  P. 

2  Boston  Medical  and  Surgical  Journal,  May  26,  18S1. 


CEREBRAL    SCLEROSIS.  199 

Treatment.— Our  first  indication  is  to  improve,  if  possible,  the  or- 
ganic disease,  and  sometimes  we  are  able  to  better  the  patient's  condi- 
tion to  a  great  degree.  Should  there  be  hemiplegia,  contractures,  or 
other  evidences  suggestive  of  degeneration  of  the  cerebral  tissue,  we  will 
find  ourselves  powerless  to  help  our  patient  materially.  It  is  only  when 
aphasia  exists  as  an  isolated  symplom  that  very  active  measures  are  fol- 
lowed by  some  show  of  success.  In  such  a  case  local  blood-letting, 
purgation,  and  the  use  of  ergot,  and  the  bromides,  may  completely  relieve 
the  condition  ;  and  even  when  the  disease  is  established,  and  the  de- 
struction of  the  speech  centre  has  been  limited,  there  is  a  possibility  of 
improving  the  patient's  partially  lost  faculty.  Systematic  education, 
and  the  training  of  the  left  hand,  and  the  development  of  the  right  side  of 
the  brain,  may  result  in  an  increase  in  the  patient's  faculty  of  communi- 
cating. In  rare  cases,  viz.,  those  of  traumatic  origin,  it  may  do  well  to 
use  the  trephine.  Broca,  under  the  heading,  "  La  Topographic  Cranio- 
Cerebrale,"^  described  experiments  made  by  him  to  determine  the 
relation  of  the  cranial  bones  with  underlying  parts ;  and  Turner  ^  has 
made  additional  observations,  and  given  rules  for  determining  this  rela- 
tion. 

CEREBRAL  SCLEROSIS. 

Synonyms. — Sclerencephalia ;  atrophia  cerebri.  Tabes  cerebri. 
Atrophy  of  the  brain. 

Definition. — An  induration  of  the  nervous  substance,  consisting  in 
increase  of  connective  tissue,  and  atrophy  and  destruction  of  the  nervous 
elements,  constitutes  the  condition  known  generally  as  sclerosis.  The 
French  writers  have  applied  the  terms  "  Sclerose  en  plaques  disseminee," 
"rubanee,"  " peripheriques,"  and  "difius"  to  the  disease;  adopting  these 
names  in  regard  to  the  character,  site,  and  form  of  the  lesion.  Such  ex- 
pressions, while  making  the  nomenclature  more  exact,  imply  delicate 
distinctions  which  are  not  always  to  be  made,  and  do  very  well  only  when 
applied  to  appearances  witnessed  after  death,  but  are  not  so  valuable 
when  making  a  diagnosis  before  death.  I  prefer  to  use  the  tei-ms  "  dif- 
fused sclerosis"  of  the  brain,  " cerebro-spinal  sclerosis,"  and  "spinal 
sclerosis."  Even  this  nomenclature  is  open  to  objection,  for  it  is  very- 
rare  for  sclerosis  of  any  kind  to  be  confined  to  either  the  brain  or  cord, 
though  such  involvement  of  the  organ  not  originally  affected  may  be  of 
late  date.  To  confirm  this  statement  I  may  allude  to  the  ocular  symp- 
toms which  characterize  the  early  manifestations  of  posterior  spinal 
sclerosis,  or  the  locomotory  defects  that  are  to  be  seen  in  some  sclerosed 
conditions  supposed  to  be  peculiarly  cerebral.  I  may  furthermore  add 
that  in  all  forms  of  sclerosis  there  are  generally  points  of  induration 
found  after  death  in  both  brain  and  cord.     Nevertheless,  it  is  important 

1  Revue  d'  Anthropologic,  tome  v.  No.  2,  1876. 

^  Journal  of  Anatomy  and  Physiology,  vols  xii,  xiv,  1873,  1874. 


200         DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

for  US  to  make  distinctions  in  the  manner  and  origin,  course  and  termina- 
tion of  the  various  forms  of  the  disease,  and  we  must  therefore  be  con- 
tented with  an  anatomical  division. 

DIFFUSED    CEREBRAL   SCLEROSIS. 

The  older  writers  were  in  the  habit  of  giving  the  title  "  atrophy  of  the 
brain  "  to  a  condition  of  that  organ  which  was  undoubtedly  that  which 
we  are  now  discussing.  It  is  probably  one  of  the  most  imperfectly  un- 
derstood nervous  diseases,  and  in  many  instances  the  diagnosis  cannot  be 
made  during  life. 

Symptoms. — The  cerebral  condition,  which  is  tardy  induration  of 
an  unlimited  region,  and  does  not  consist  in  scattered  deposit-s,  is  a  slowly 
developed  morbid  state,  and  is  expressed  by  a  train  of  rather  obscure 
symptoms,  the  most  striking  of  which  are  contractions  and  epileptiform 
convulsions,  impairment  of  mental  power,  and  various  affections  of 
speech.  In  some  cases  the  conditions  date  from  infancy,  and  the  charac- 
teristic feature  is  want  of  development  of  the  extremities.  In  others,  a 
condition  of  imbecility  exists,  in  which  the  patient  leads  almost  a  vegeta- 
tive life.  One  case  (No.  II.),  which  I  shall  relate,  was  of  this  kind. 
Her  last  years  of  life  were  spent  in  bed,  and  for  a  long  time  there  were 
dementia  and  unconscious  discharges  from  the  bladder  and  bowels.  Some 
of  these  cases  begin  later  in  life,  and  the  first  indications  may  be  either 
tremor  or  an  epileptiform  convulsion,  and  subsequently  various  disturb- 
ances of  motility,  such,  for  instance,  as  spastic  contraction  of  the  muscles 
of  the  arm  and  leg,  and  the  fingers  become  twisted,  deformed,  and  distorted 
so  as  to  be  useless.  Tremor  is  not  rare,  and  as  the  disease  advances  there 
may  be  various  other  symi^toms,  such  as  paralysis  and  muscular  atrophy, 
as  well  as  glosso-labial  paralysis.  Psychical  disturbances  are  early  symp- 
toms, and  a  species  of  dementia  is  rapidly  produced. 

Case  I. — Mary  J.,  the  patient,  a  girl  14  years  old,  was  brought  to  me 
during  the  month  of  September,  1871.  She  had  been  very  ill  some  six 
years  before,  and  from  what  I  learned  from  the  mother,  the  attack  of 
illness  must  have  been  scarlatina,  or  some  other  eruptive  fever.  Her 
convalescence  was  slow,  and  attended  by  convulsions  of  an  epileptoid 
character.  She  slept  much  of  the  time,  and  seemed  dull  and  stupid. 
Her  memory  became  impaired,  so  that  her  mother  was  obliged  to  take 
her  from  school,  and  when  allowed  to  play  she  quarrelled  with  the  child- 
ren in  the  neighborhood,  and  became  so  warlike  that  it  was  found  neces- 
sary to  keep  her  at  home.  When  she  had  suffered  for  over  a  year  in 
this  way,  she  began  to  lose  her  power  of  speech,  and  when  she  attempted 
to  converse  with  those  who  spoke  to  her  she  talked  in  an  unintelligible 
manner ;  the  tongue  "seemed  to  be  paralyzed."  In  1868  her  arms  be- 
came very  weak,  and  trembling  grew  violent  when  she  made  any  manual 
effort.  This  loss  of  power,  which  was  observed  more  in  the  right  arm, 
became  so  great  that  she  was  unable  to  u^e  it  in  any  way  whatever. 
After  a  year  or  so  the  arm  became  rigid  and  atrophic,  and  within  twelve 
months  the  other  arm  followed.  She  is  now  in  a  condition  of  imbecility. 
She  holds  her  head  very  far  forward  when  she  walks,  her  chin  being 


CEREBRAL    SCLEROSIS.  201 

raised.  The  right  pupil  is  slightly  larger  than  the  left.  There  is 
ataxic  loss  of  speech,  the  tongue  being  entirely  out  of  control,  but 
nevertheless  she  incessantly  tries  to  talk.  Her  senses  are  but  slightly 
impaired,  and  it  may  be  said  she  hears  well,  if  we  can  place  any  re- 
liance upon  the  rough  tests  I  made,  such  as  speaking  to  her  behind  her 
back.  Her  sensibility  to  pain  is  not  apparently  lost,  for  she  gives  ex- 
pression to  signs  of  suffering  when  she  is  pinched,  but  she  complains  of 
dysaesthesia. 

Her  right  arm,  forearm,  and  hand  are  semiflexed  and  rigid,  and  the 
atrophy  of  the  palmar  muscles  suggests  the  "  main  en  griffe."  Her  nails 
are  long  and  thick,  and  the  skin  not  only  of  this  hand,  but  that  covering 
the  hand  and  arm  of  the  other  side,  is  blue  and  cold  The  flexors  carpi 
radialis,  palmaris  longus,  pronator  radii  teres,  and  other  muscles  upon  the 
anterior  aspect  of  the  forearm  were  atrophied  and  contracted,  as  well  as 
the  extensores  communis  and  minimi  digiti.  This  appearance  was  found 
on  both  sides,  but  more  so  on  the  right.  When  she  makes  any  voluntary 
movement,  the  tremor  occurs,  and  it  is  like  that  which  marks  other 
forms  of  this  disease  ;  that  is  to  say,  it  is  increased  by  persistence  in  the 
attempt.  The  arms  are  the  only  parts  affected  by  the  tremor.  Her  con- 
vulsions occur  about  twice  a  week. 

Case  II. — M.  S.,  aged  18  years,  admitted  to  hospital  June  21,  1873. 
When  the  patient  was  fifteen  months  of  age  she  had  her  first  epileptic  con- 
vulsions. These,  according  to  her  stepmother,  have  gradually  increased 
in  number.  At  ten  years  of  age  she  became  paralyzed.  The  paralysis 
afiected  her  right  side,  and  came  on  gradually,  without  loss  of  conscious- 
ness ;  and  it  has  increased  so  that  at  present  all  the  muscles  of  the  extre- 
mities, and  some  of  those  of  the  face,  are  paralyzed.  Sensibility  is  not 
afiected.  She  has  imperfect  control  of  the  voluntary  muscles,  and  does 
not  use  them  readily  ;  and  when  spoken  to  does  not  appear  to  appreciate 
what  is  desired  immediately. 

Dynamometer  :  left  side  15,  right  side  19. 

The  gesthesiometer  was  not  used,  as  the  patient  was  too  much  demented 
to  appreciate  what  was  wanted. 

Her  head  is  very  large,  the  patient  being  of  ordinary  stature.  The 
saliva  flows  continually  from  the  corner  of  her  mouth,  and  her  com- 
plexion is  dusky  and  bad.  The  muscles  are  all  more  or  less  atrophied. 
Heart  and  lungs  are  normal ;  no  murmurs  other  than  the  venous  hum  of 
anaemia. 

The  patient  came  under  my  care  in  June,  1876.  She  was  then  in  a 
condition  of  profound  dementia.  She  had  been  in  bed  for  some 
months,  and  when  I  examined  her  I  found  her  conditions  to  be  the  fol- 
lowing : — 

There  were  no  constant  ocular  defects,  no  ocular  paralysis,  and  the 
pupils  responded  well ;  but  there  had  been  occasional  attacks  of  uncon- 
sciousness, attended  by  nystagmus,  when  her  eyeballs  would  move  from 
left  to  right.  There  was  slight  paralysis  of  the  buccal  muscles,  and  the 
mouth  was  almost  constantly  open  ;  while  a  profuse  secretion  of  saliva 
drooled  from  the  angle  of  the  mouth  and  over  her  undergarments  and 
bed-clothes.  Her  mouth  contained  partially  masticated  food,  of  which 
there  was  an  accumulation  between  her  teeth  and  cheeks  on  either  side. 
Her  teeth  were  very  filthy,  and  the  gums  tender  and  bleeding.  No 
appreciative  facial  paralysis  was  detected.  When  spoken  to  she  smiled 
in  an  inane  manner,  but  did  not  attempt  to  speak.     She  was    occasionally 


202        DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

very  apt  to  cry  for  several  hours  at  a  time,  and  seemingly  without  causa. 
Her  position  in  bed  was  an  exceedinrrly  uncomfortable  one  ;  she  usually 
reclined  upon  her  left  side,  the  head  drawn  down  to  the  same  side  ;  and 
it  was  agitated  by  coarse  tremors,  which  ceased  when  she  slept.  Her 
right  arm  and  forearm  were  drawn  to  her  chest,  and  likewise  agitated  by 
almost  constant  tremors.  Her  left  arm  was  also  adducted,  and  the  fore- 
arm semi-flexed  ;  while  the  fingers  were  extende  1.  Tremors  of  the  same 
character  agitated  this  member.  The  thighs  and  legs  were  drawn  up, 
but  did  not  seem  to  be  quite  so  rigid  as  the  arms,  and  there  was  great 
atrophy  of  all  four  extremities.  She  passed  her  excreta  unconsciously, 
and  a  bedsore  had  formed  upon  the  left  buttock.  Voluntary  power 
was  absent  almost  entirely,  and  I  do  not  remember  having  seen  her 
change  her  position  in  bed  from  the  time  I  first  saw  her  until  her  death. 
Sensibility  to  pain  was  very  much  lost,  and  reflex  excitability  was  nil. 
Perhaps  some  of  this  want  of  sensibility  was  due  to  the  horny  condition 
of  the  plantar  skin.  She  had  a  great  many  general  convulsions,  attended 
by  turgescence  of  the  surface  vessels,  and  nystagmus.  She  contiaued  in 
this  condition  during  the  year,  improving  slightly  during  this  time  in 
regard  to  the  number  and  violence  of  convulsions,  but  gradually  growing 
weaker. 

Dec.  26,  1876,  1.30  P.  M.  Being  fed  with  stewed  meat  she  had  three 
convulsions  in  rapid  succession,  while  her  mouth  was  filled  with  food. 
Attendant  states  that  she  first  became  cyanotic,  but  her  teeth  were  so 
clenched  that  the  nurse  was  unable  to  extract  the  food.  As  soon  as  the 
spasms  relaxed,  she  thrust  her  fingers  in  the  mouth  of  the  patient,  and 
removed  a  piece  of  meat,  but  the  patient  was  dead. 

Autopsy  18  honrs  after  death. — No  food  found  in  larynx  or  fauces. 
Membrane  of  brain  congested  and  thickened  ;  the  gray  matter  of  all 
the  convolutions  was  of  the  consistency  of  the  white  of  a  hard-boiled 

I  afterwards  carefully  examined  the  brain,  and  found  patches  of  ad- 
vanced sclerosed  tissue  over  the  coitex,  and  throughout  the  gray  and 
white  matter  of  other  parts  of  the  hemispheres.  The  induration  was  so 
general  that  the  brain  seemed,  as  a  whole,  quite  hard  and  tough.  The 
arteries  were  diseased  throughout,  and  the  calibre  of  the  vessels  was 
quite  reduced. 

Case  IH. — This  patient  presents  evidences  of  cerebral  sclerosi-s,  which 
were  evidently  of  very  early  origin.  The  patient  is  at  present  in  the 
Epileptic  and  Paralytic  Hospital.  Her  early  history  is  somewhat  meagre. 
She  gives  a  history  of  epilepsy,  and  has  attacks  several  times  a  week. 
Her  mind  is  very  feeble,  and  she  has  attempted  suicide  several  times. 
The  atrophy  is  one-sided,  and  there  is  probably  atrophy  of  the  left  side  of 
the  brain.  The  fiillowing  history  and  table  of  measurements  were  fur- 
nished by  my  predecessor.  Dr.  Janeway  : — 

E.  B.,  aged  19  years;  state  single.    Admitted  to  hospital  May  1, 1868. 

Examination. — Head:  no  facial  paralysis  or  deviation  of  tongue;  no 
atrophy  of  tongue;  pupils  normal,  no  strabismus  ;  hearing  good,  as  is  also 
common  sensibility.  Right  upper  extremity  :  shoulder-joint  is  freely 
movable;  elbow  cannot  be  fully  extended  ;  hand  flexed  and  extremely 
pronated ;  muscles  of  hand  to  a  certain  degree  rigid  ;  fingers  flexed, 
thumb  not  rigid  ;  marked  atrophy  of  entire  arm;  skin  of  fingers  soft  and 
sodden,  but  no  other  changes  of  nutrition. 

Measurements. — Middle  sternal  notch  to  coracoid  process :  right  side. 


CEREBRAL    SCLEROSIS.  203 

4i  inches  ;  left  side,  4f  inches.  Edge  of  acromion  to  external  condyle ; 
right  side,  lOi  inches;  left  side,  lOj  inches.  External  condyle  to  styloid 
process  of  ulna:  right  side,  7?  inches;  left  side,  84-  inches.  Apex  of 
acromion  to  styloid  process  :  right  side,  74  inches  ;  left  side,  8  inches. 

1st  metacarpal  bone  (index  finger) :  right  side,  50  mm.  ;  left  side,  65 
mm.  Metacarpal  bone  (little  finger) :  right  side,  47  mm.  ;  left  side,  50 
mm.  Metacarpal  (thumb)  :  right  side,  40  mm. ;  left  side,  43  mm. ;  right 
index,  65  mm. ;  left  index,  70  mm.  Little  finger:  right  side,  53  mm.; 
left  side,  60  mm. 

Thenar  eminence,  thickness  of:  right,  31  mm.;  left,  35  mm.  Hypo- 
thenar  eminence,  thickness  of:  right,  20  mm.  ;  left,  24  mm. 

Vertebral  prominence  to  edge  of  acromion  :  right  side,  6^  inches  ;  left 
side,  7i  inches.  Inner  edge  scapula  to  supra-spinal  notch,  to  deltoid : 
right  side,  12f  inches;  left  side,  141  inches.  Length  inner  border  sca- 
pula :  right,  51  inches  ;  left,  5i  inches. 

Semi-circumference  thorax  (4th  rib)  :  right,  13 J  inches;  left,  14} 
inches. 

Sensibility  of  right  hand  normal  in  every  respect.  Dynamometer :  first 
trial  in  left  hand,  18  ;  second  trial,  10.  Hardly  any  power  of  right  hand, 
but  reflex  movements  are  readily  excited  in  it.  Circumference  :  right 
arm,  8 J  inches;  right  forearm,  8}  inches  ;  left  arm,  9?  inches;  left  fore- 
arm, 9f  inches. 

Lower  extremities :  left,  length  of  fibula,  I3i  inches ;  right,  length  of 
fibula,  134  inches;  right  calf.  Hi  inches;  left  calf,  12|  inches.  Lower 
edge  patella  to  lower  edge  external  malleolus:  right,  ISi  inches  ;  left, 
13f  inches.  Anterior  edge  inner  malleolus  to  end  of  great  metatarsal : 
right,  4i  inches  ;  left,  4}  inches.  Circumference  over  heads  of  metatarsal 
bones  :  on  right  side,  7J  inches  ;  on  left  side,  7?  inches.  Anterior  sup. 
spinous  process  to  lower  malleolus  :  right,  283-  inches  ;  left.  28i  inches. 
Supra-s'ernal  notch  to  lower  edge  of  external  malleolus  :  right,  45}  in- 
ches ;  left,  48f  inches. 

Sensibility  of  legs  good  in  all  respects.  Difierence  of  malleoli  as  she 
lies  in  bed,  i  inch. 

Causes. — So  little  is  known  in  regard  to  the  circumstances  favoring 
the  development  of  this  disease,  that  beyond  the  mention  of  certain  facts 
of  age  and  sex  nothing  more  can  be  said  in  connection  with  etiology. 
Women  seem  to  be  more  affected  than  males,  and  we  may  consider  that 
it  is  usually  a  condition  that  begins  in  infancy  and  progresses  slowly,  or 
is  arrested  ;  or,  on  the  other  hand,  it  may  begin  in  advanced  life,  and 
progress  more  rapidly.  In  one  case  which  I  have  seen,  syphilis  had  proba- 
bly something  to  do  with  its  development.  Scarlet  fever  or  acute  diseases 
of  the  brain  are  apt  sometimes  to  leave  behind  a  certain  amount  of 
induration. 

Morbid  Anatomy. — Those  authors  who  have  made  autopsies  have 
found  a  condition  of  density  of  the  white  matter,  the  same  being  shrunken 
and  more  firm  at  the  centre  of  the  hemisphere  than  at  the  periphery. 
"When  a  microscopical  examination  is  made,  the  brain-tissues  are  found  to 
show  appearances  which  are  highly  characteristic.  The  connective  tissue 
will  be  found  to  be  proliferated,  and  to  present  a  fibrillated  appearance. 
Corpora  amylacea  are  often  present,  and  we  usually  find  granular  deposits 


204         DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

in  the  blastema.  The  new  tubes  are  quite  changed  in  character,  and  are 
shrunken  and  attenuated.  The  axis  cylinder  may  have  disappeared,  and 
its  place  may  be  filled  by  a  granular  substance.  The  nerve-cells  are 
greatly  altered,  their  prolongations  being  torn  off,  and  their  contents 
granular.  Oil-globules  are  often  found  scattered  over  the  field,  and  some- 
times collected  about  the  blood  vessels.  These  vessels  are  generally  much 
increased  in  size,  and  their  walls  are  thickened,  and  covered  by  a  granu- 
lar deposit.  If  the  gray  matter  be  the  part  aflPected,  we  shall  find  an  un- 
usual development  in  the  blood  vessels. 

I  have  spoken  of  the  involvement  of  the  cranial  nerves.  It  is  not  un- 
common to  find  at  the  roots  of  this  nerve  a  sclerosed  point  which  has 
involved  the  nuclei. 

Diagnosis. — Diffused  sclerosis,  in  its  incipiency,  may  be  mistaken  for 
cerebral  softening,  but  though  the  two  diseases  seem  very  much  alike,  the 
absence  of  severe  pain,  and  variations  of  temperature  in  the  latter,  as  well 
as  subsequent  progress  of  the  disease,  will  enable  us  to  decide  ;  it  must  be 
borne  in  mind,  however,  that  in  the  great  number  of  cases  diffused  sclero- 
sis begins  in  very  early  life.  The  congenital  cerebral  non-development 
which  we  sometimes  see  will  be  recognized  by  the  absence  of  tremor,  but 
we  must  not  confuse  such  cases  with  those  of  early  intracranial  disease 
where  spastic  paralysis  and  increased  tendon  reflex  are  conspicuous. 

Prognosis  and  Treatment. — The  former  is  excessively  bad,  and 
even  temporary  relief,  I  think,  is  out  of  the  question  in  the  great  majority 
of  cases.  I  have  never  seen  a  case  cured  ;  and  if  there  is  any  disease  of 
the  nervous  system  that  is  utterly  beyond  the  reach  of  drugs,  I  am  con- 
fident that  it  is  this.  The  actual  cautery  has  been  used,  but,  as  far  as  I 
can  learn,  without  benefit.  The  treatment  of  individual  symptoms  may 
greatly  increase  the  comfort  of  the  patient,  and  with  this  object  hyoscya- 
mine  in  doses  of  from  gr.  iJo  to  gr.  25  may  be  given  to  quiet  the  tremor  or 
spasm.  For  the  convulsions  the  free  use  of  ergot  does  good,  while  as  rou- 
tine treatment  it  is  advisable  to  administer  the  salts  of  silver  or  mercury. 


BRAIN    TUMORS.  205 


CHAPTER    Yl 

DISEASES  OF  THE  CEREBRUM  AND  CEREBELLUM. 

(Continued). 

BRAIN   TUMORS. 

When  the  brain  chances  to  be  the  seat  of  a  morbid  growth,  whether 
vascular,  or  parasitic  ;  homologous,  or  heterologous,  we  may  be  apprised  of 
the  existence  of  such  a  new  formation  by  a  train  of  symptoms  which 
have  no  very  constant  character  ;  or  the  tumor  may  even  involve  a  large 
part  of  the  brain  without  giving  rise  to  any  indications  of  its  presence 
during  the  life  of  the  patient.  There  is  no  regularity  as  to  the  grouping 
or  appearance  of  symptoms,  although  the  very  valuable  researches  of 
Hughlings  Jackson  have  enabled  us  to  define  the  position  of  the  morbid 
intracranial  growths  with  much  greater  certainty  than  heretofore. 

Symptoms. — We  may  group  the  prominent  symptoms  under  the 
following  heads  : — 

1.  Convulsions. 

2.  Vomiting  and  vertigo. 

3.  Headache  and  cutaneous  hypersesthesia  or  ansesthesia. 

4.  Hemiplegia. 

5.  Paralysis  of  cranial  nerves. 

6.  Ocular  symptoms. 

7.  Psychical  disturbances. 

Convulsions. — The  appearance  of  convulsions  as  the  only  indication  of 
brain  tumors  has  frequently  led  the  observer  to  make  a  diagnosis  of  epi- 
lepsy However,  when  it  is  taken  into  account  that  there  is,  at  the 
most,  but  transitory  loss  of  consciousness — and  even  this  is  very  rare — 
during  the  epileptiform  attack,  such  a  mistake  is  hardly  possible.  The 
convulsions  may  be  general  or  local,  and  in  this  place  it  is  proper  to 
refer  to  the  connection  between  certain  cortical  lesions  produced  by  brain 
tumors,  and  consequent  convulsions  beginning  in  members  which  are  sup- 
posed to  have  motor  centres.  Among  sixteen  cases  collected  by  Hugh- 
lings  Jackson  there  were  several  in  which  the  convulsive  seizure  began  in 
the  thumb  of  one  hand,  and  finally  became  general.  Cortical  lesions 
were  found  in  the  third  frontal  convolution.  lu  another  the  epileptiform 
seizure  began  in  the  right  cheek,  and  still  another  is  reported  where  the 
right  arm  was  the  point  of  seizure,  with  subsequent  paralysis ;  and  after 
death  a  tumor  was  found  in  the  uppermost  frontal  convolution  on  the 
opposite  side.     Upon  the  authority  of  Bastiau  ^  and  Reynolds,  "  it  may 

1  Op.  cit.,  p.  493. 


206         DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

be  stated  that  convulsions  are  most  common  when  the  disease  is  situated 
in  the  posterior  lobes  of  the  brain  or  in  the  cerebellum,  and  least  fre- 
quent when  the  anterior  lobes  are  affected."  This  statement  must  be 
considered  to  apply,  however,  mostly  to  those  cases  presenting  general 
convulsion.  Local  spasms,  which  may  even  be  followed  by  general  con- 
vulsion, begin  in  the  limb  innervated  by  a  psychomotor  centre,  and  are 
significant  diagnostic  signs. 

Hughlings  Jackson  considers  that  psychical  disturbances  are  likewise 
connected  with  destruction  or  injury  of  the  posterior  lobes.  When  the 
growth  is  syphilitic,  the  presence  of  much  headache  before  the  convul- 
sion is  the  rule.  Convulsions  may  be  the  first  symptoms  of  tumor,  and 
when  they  occur  in  advanced  life  there  is  always  occasion  for  suspicion. 
Several  writers  have  agreed  that  convulsions  and  other  symptoms  are  the 
result  of  irritation  of  parts  adjacent  to  the  tumor,  and  that  they  may 
vary  in  appearance  and  severity  in  proportion  to  the  local  disturbance 
created  by  the  growth ;  for  this  reason  convulsions  may  appear  in  the 
most  irregular  manner.  Pain  is  one  of  the  earliest  and  most  persistent 
symptoms.  It  is  nearly  always  localized,  and  is  very  intense,  especially 
if  the  meninges  be  affected  in  any  way,  when  it  may  be  combined  with 
muscular  twitchings.  It  is  rare  for  it  to  subside  for  an  extended  period, 
and  then  reappear ;  and  in  such  cases  it  is  highly  probable  that  the 
growth  has  either  expanded  in  some  other  direction,  or  that  the  tissues 
have  become  accustomed  to  its  presence  in  the  manner  suggested  by 
Niemeyer.  Pain  aggravated  at  night  is  highly  suggestive  of  a  syphilitic 
tumor. 

Photophobia  is  sometimes  a  symptom,  and  intolerance  of  noise  is  a 
decided  feature,  while  vertigo  is  produced  by  very  slight  irritation,  and  it 
has  been  found  in  tumors  which  injure  the  corpora  quadrigemina  that 
this  occurs  when  the  patient  closes  his  eyes.  Such  was  noticed  to  be  the 
case  in  an  examjjle  reported  by  Dr.  Duffin.  This  patient,  a  man  aged 
twenty-five,  presented  the  following  symptoms  :  A  dragging  of  the  mus- 
cles at  the  back  of  the  neck,  so  that  the  head  was  pulled  downwards  and 
backwards,  unsteady  walk,  vertigo  when  eyes  were  closed,  vomiting,  fre- 
quently slow  and  irregular  circulation,  obscured  intelligence,  double  optic 
neuritis,  defective  sight,  and  finally  coma,  A  gliomatous  tumor  was 
found  which  had  destroyed  the  pineal  gland,  and  extended  into  the  optic 
thalamus.  Reeling  is  commonly  associated  with  vertigo,  and  is  generally 
symptomatic  of  a  growth  in  the  substance  of  the  cerebellum.  Symptoms 
of  minor  importance  are  cutaneous  anaesthesia  or  hypersesthesia,  with 
tingling  or  formication  of  the  hands  or  feet.  Such  anaesthesia  may  affect 
the  tract  supplied  by  the  fifth  nerve,  while  deep  cerebral  pain  may  co- 
exist. This  combination  is  almost  pathognomonic,  and  should  be  looked 
upon  with  suspicion.  Total  abolition  of  cutaneous  sensibility  in  connec- 
tion with  cerebral  tumors  has  been  studied  by  '  Ball  and  Krishaber.     Of 

'  Tiimeurs  Cerebrales  art.  in  Dictionnaire  Encyclopedique,  p.  456. 


BRAIN    TUMORS.  207 

185  cases  of  cerebral  tumor  it  was  found  that  sensibility  was  abolished  in 
but  fifteen  instances.     In  seven  others  it  was  simply  blunted. 

Hemiplegia  is  not  an  uncommon  symptom,  and  may  be  sudden  when 
produced  by  the  rupture  of  a  vessel;  or  of  gradual  origin,  as  the  result  of 
pressure  made  upon  important  parts  of  the  motor  tract  by  a  tumor  of 
slow  growth.  By  far  the  most  significant  paralyses  are  those  of  local 
origin,  connected  with  local  spasms,  and  these  usually  indicate  a  lesion  in 
the  cortical  motor  zone.  Paralysis  is  generally  a  late  symptom,  and 
may  begin  by  loss  of  power  of  one  member,  and  afterwards  of  the  other 
of  the  same  side.  By  far  the  most  interesting  paralyses  are  those  of 
the  cranial  nerves,  because  of  their  value  as  diagnostic  signs ;  and  not 
only  may  the  optic  nerve  be  afiected,  but  the  auditory,  motor  oculi,  and 
even  the  fifth,  may  suffer  an  alteration  of  function. 

Jackson  and  others  are  of  the  opinion  that  those  muscles  concerned 
more  in  the  execution  of  direct  voluntary  movements  are  often  affected 
in  a  greater  degree  than  those  which  perform  automatic  movements  al- 
most exclusively. 

Paralysis  of  both  external  recti  muscles  occurred  in  one  of  Jackson's 
cases,  and  is,  perhaps,  one  of  the  most  significant  indications  of  the  pre- 
sence of  gummata.  Lateral  deviation  of  the  eyes  from  the  side  of  the 
lesion  is  also  a  form  of  cranial  nerve  paralysis  which  is  by  no  means  a 
rare  symptom.  In  a  case  reported  by  Afanaschiff",^  where  a  tumor  was 
found  in  the  right  crus,  there  was  dilatation  of  the  pupil  and  ptosis.  Par- 
tial paralysis  of  the  face,  showing  involvement  of  the  seventh,  and  actual 
deafness,  are  not  rare  consequences  of  injury  sustained  by  the  seventh 
nerve.^  When  the  fifth  nerve  is  affected,  as  in  one  of  Broadbent's  cases, 
there  is  generally  marked  ansesthesia  of  the  region  supplied  by  this  nerve, 
with  difficult  mastication,  deglutition,  and  articulation.  Bed  sores  are 
not  met^with  in  connection  with  paralysis  in  cases  of  cerebral  tumor,  nor 
do  they  occur  as  a  result  of  cerebral  pachymeningitis ;  they  are  rather 
the  result  of  hemorrhage  into  nervous  substances.  The  most  im- 
portant evidences  are  seen  at  the  fundus  oculi,  and  by  some  optic  neu- 
ritis is  considered  to  be  a  positive  sign  of  brain  tumor.  Russel,^  in 
the  description  of  a  very  instructive  case,  details  an  examination  of  the 
fundus.  This  may  be  considered  a  typical  example,  although  the  retinal 
appearances  were  in  an  advanced  stage.  He  found  "loss  of  vision  com- 
plete, neuro-retinitis  of  both  eyes.  Right  disk  comparatively  invisible, 
even  its  position  not  clearly  distinguishable.  Position  of  left  disk  indi- 
cated by  short  portion  of  retinal  vessels,  which  were  visible  near  their 
point  of  convergence.  Region  around  the  disk  in  each  eye  occupied  by 
large  irregular  patches  of  hemorrhage,  some  recent,  others  undergoing 


1  Wien.  Med.  Woch.,  1870,  No.  9. 

''■  H.  Jackson  does  not  believe  that  tumors  of  the  cerebrum  or  cerebellum  produce 
deafness,  unless  the  auditory  nerves,  he  pressed  upon. 

2  Med.  Times  and  Gazette,  July  26,    1873. 


208         DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

absorption.  Only  very  small  portions  of  retinal  vessels  are  here  and 
there  visible." 

Complete  atrophy  of  the  optic  disk  is  generally  to  be  observed  in  cases 
where  the  retinitis  has  existed  for  some  time. 

Hughlings  Jackson  calls  especial  attention  to  the  fact  that  loss  of  vision 
is  not  Inseparable  from  optic  neuritis,  though  complete  blindness  often 
does  occur.  He  has  seen  cases  in  which  there  Avas  a  double  optic  neuritis, 
though  the  patients  were  able  to  read  the  smallest  type.^ 

A  very  important  appearance  observed  at  the  fundus,  and  known  as 
"choked  disk"  or  "congestion  papilla,"  is  often  produced  by  brain  tu- 
mors. In  fact,  when  not  a  peripheral  condition,  it  is  almost  always,  ac- 
cording to  Swanzy,'  connected  with  intracranial  tumors,  hydrocephalus, 
or  meningitis ;  but  when  it  is  produced  by  these  morbid  conditions  it  is 
usually  binocular.  "Choked  disk"  may  be  caused  by  a  tumor  in  any 
part  of  the  brain,  whether  it  be  in  the  cerebellum  or  cerebrum,  and  it  is 
not  necessary  that  the  optic  nerve  shall  be  implicated  either  at  its  origin 
or  in  its  course.  Another  fact  is  of  importance,  viz.,  that  the  size  of  the 
tumor  has  nothing  to  do  with  the  production  of  the  condition,  and  a  small 
tumor  may  produce  choked  disk  as  well  as  a  large  one.  The  appearance 
of  choked  disk  is,  in  substance,  the  following.     The  disk  may  be  seen  to 

Fig.  27. 


Choked  Disk.    (After  Leibreich.) 


be  prominent,  the  fibres  are  swollen,  and  the  papillary  region  is  some- 
times of  a  dark  reddish-gray,  much  change  of  color  being  due  to  passive 
effusion  and  old  hemorrhage.  The  disk  may,  in  other  cases,  be  of  a 
bright  color.     There  may  be  some  evidences  of  retinal  extravasation. 


1  Koyal  London  Ophthalmic  Hospital  Report'*,  vol.  iv.,  186.5. 
■^  Signs  of  Congestive  Papilla  or  Choked   Disk  in  Intracranial  Disea.se. 
Swanzy,  M.  B.,  F.  R.  C.  S.,  Dublin  Journ.  of  Med.  Science,  June.  1874. 


H.  R. 


BRAIN    TUMORS. 


209 


Fiff.  28. 


which  are  uot  found  at  any  great  distance  from  the  edge  of  the  disk,  and 
Albutt^  says  not  more  than  a  distance  of  the  radius  from  the  edge. 
The  margin  of  the  disk  is  concealed  by  infiltration  and  by  vascularity, 
■which  give  it  a  "mossy"  appearance.  The  central  radiating  appearance 
resembles  very  much  a  scintillating  body,  while  the  retinal  veins  are  dis- 
tended and  tortuous,  are  quite  serpentine  in  their  course,  and  may  even 
be  varicose. 

I  cannot  agree  with  Albutt,  who  considers  the  recognition  of  any  prom- 
inence of  the  disk  a  difficult  matter,  and  I  think  that  this  is  the  opinion 
of  the  majority  of  ophthalmologists. 

As  interesting  features  of  this  as  well  as  other  forms  of  cerebral  disease, 
may  be  mentioned  such  ocular  trouble  as  hemiopia  and  amblyopia. 
Charcot  was  the  first  person  to  consider  the  significance  of  these  symptoms 
and  their  connection  with  hemianaesthesia,  and  he  has  done  much  for 
both  neurology  and  ophthalmology  in  explaining  the  direction  of  the  fibres 
in  the  optic  tracts. 

Scheme  of  the  Decussation  of  the  Optic 
Tracts,  according  to  Charcot :  T.  Semi- 
decussation in  the  optic  chiasma.  T  Q. 
Decussation  posterior  to  the  corpora  geni- 
culata.  C  G.  Corpora  geniculata.  a  h'. 
Fibres  which  do  not  decussate  in  the  chi- 
asma. h'  a.  Fibres  which  undergo  decus- 
sation in  the  chiasma.  h'  a'.  Fibres  com- 
ing from  the  right  eye,  which  meet  in  the 
left  hemisphere,  LOG.  LOB.  Right 
hemisphere.  K.  Lesion  in  the  left  optic 
tract,  producing  right  lateral  hemiopia. 
L  0  G.  A.  lesion  at  this  point,  right  am- 
blyopia. T.  Lesion  producing  temporal 
hemiopia.  NN.  Lesion  producing  nasal 
hemiopia. — Ferrier. 

It  will  be  seen  by  reference  to  the  appended  diagram  presented  by 
Charcot  originally,  and  modified  by  Ferrier,  that  complete  decussation 
of  the  fibres  of  the  optic  nerve  (a  a,  b'h')  does  not  take  place,  but  that 
certain  internal  fibres  (a'  a',  h  b)  decussate  in  the  optic  commissure,  while 
others  decussate  further  back  in  the  tubercula  quadrigemina ;  and  that  there 
is  a  still  further  complicated  arrangement,  so  that  these  fibres  ultimately 
centre  in  the  cortex  at  the  pli  courbe  or  angular  gyrus.  It  will  also 
be  seen  how  injury  to  these  fibres  or  pressure  by  a  tumor  or  other  lesion 
may  produce  several  varieties  of  hemiopia.  Ferrier  describes  the  pro- 
duction of  visual  troubles  as  follows  :  "  Lesion  of  the  left  side  of  the 
chiasma  or  of  the  left  optic  tract  (K),  will  cause  hemiopia  of  both  eyes, 
paralyzing  the  left  side  of  both  retinae.  The  external  fibres,  or  those 
which  do  not  decussate  in  the  chiasma,  decussate  with  their  fellows  in  the 


14 


^  The  Ophthalmoscope,  etc.,  1871,  p.  55. 


210         DISEASES    OF    THE    CEREBRUM     AND    CEREBELLUM. 

corpora  quadrigemina  (T  Q),  and  so  reach  the  opposite  hemisphere; 
while  the  fibres  which  decussate  in  the  chiasma  do  not  again  decussate  in 
these  ganglia,  but  pass  directly  through  the  corpora  geniculata  {C  G)  into 
the  hemispheres  (L  0  G,  L  0  D).  In  consequence  of  this  arrangement, 
all  the  fibres  of  the  right  eye  reach  the  left  hemisphere,  and  all  those  of 
the  left  eye  the  right  hemisphere.  Hence,  lesion  of  the  cerebral  centre 
causes  complete  blindness  of  the  opposite  eye,  while  lesions  lower  down, 
whether  in  the  corpora  quadrigemina,  corpora  geniculata  or  optic  tract, 
affecting  the  two  sets  of  fibres  before  they  have  run  their  complete  course, 
cause  partial  blindness  or  hemiopia  of  each  eye."^ 

Speech  is  generally  involved  at  some  time  or  other,  and  psychical  trou- 
bles of  all  kinds,  but  more  frequently  the  asthenic  forms,  make  their  ap- 
pearance. There  is  often  a  condition  of  hebetude  and  stupidity  which  is 
supposed  to  symptomatize  a  tumor  in  the  posterior  lobes,  or  there  may  be 
mental  decay  of  a  most  grave  character.  Delusions,  loss  of  memory, 
change  of  temper,  suicidal  tendencies,  and  various  perversions  of  intelli- 
gence may  occur  in  any  case. 

A  feature  of  cerebellar  tumor,  which  I  find  was  also  observed  by  Caton, 
was  the  assumption  by  the  patient  of  the  erect  position  as  a  means  of  re- 
lief from  the  nausea  and  desire  to  vomit.  This  author,'^  in  reporting  a 
case  of  cerebellar  tumor,  alludes  to  the  inability  of  his  patient  to  regu- 
late his  visual  co-ordination  ;  and  this  seems  perfectly  reasonable  when  we 
consider  the  paralysis  of  the  muscles  of  the  eyeball,  and  the  diplopia, 
amblyopia,  and  other  disturbances  of  visual  regulation. 

The  case  of  Miss  F.'  is  in  some  ways  instructive,  although  it  lacks 
completeness,  as  it  does  not  contain  the  report  of  au  autopsy,  the  patient 
being  still  alive  (Oct.  16,  1877)  :— 

Miss  F.,  aged  37,  U.  S.  school  teacher,  was  sent  to  me  by  Dr.  Richard 
F  Derby,  in  July,  1876.  Seven  months  ago  her  present  trouble  began 
with  weakness  of  vision,  for  which  she  consulted  Dr.  Derby,  of  Boston, 
who  adopted  Dyerization  as  a  means  of  treatment.  In  November,  1876, 
she  began  to  complain  of  severe  localized  headache  on  the  left  side  of  the 
head.  This  symptom  was  constant  for  three  months,  and  towards  the  end 
of  this  jieriod  a  gradual  hyper^esthesia  of  the  entire  left  side  developed 
itself,  which  is  now  present.  It  is  more  decided  for  three  or  four  days  at 
a  time,  when  there  is  a  lull.  There  is  also  strabismus,  which  attends  the 
paroxysms  of  acute  head  pain,  which  once  in  a  while  recur.  In  Decem- 
ber, 1^76,  there  was  some  vomiting,  which  did  not  have  any  connection 
with  the  fulness  or  emptiness  of  the  stomach.  There  is  no  loss  of  motor 
power  in  the  upper  extremity  of  either  side,  but  the  left  leg  and  foot  are 
rather  weak,  and  there  is  some  awkwardness  in  progression,  the  toe  drag- 
ging slightly.  Slight  impairment  of  electro-muscular  contractility  of 
muscles  of  leg  and  thigh.  Dynamometer  on  left  side,  9 ;  on  right,  12. 
Slight  ptosis  of  left  eye,  occasional  diplopia. 


^  Functions  of  the  Brain,  p.  168. 
*  London  Lancet,  Oct.  31,  1785, 


BRAIN    TUMORS.  211 

Dr.  Derby's  record  of  the  examination  of  her  eyes :  "  Neuro-retinitis 
o.  u.,  with  great  reduction  of  vision  o.  s. ;  moderate  reduction  o.  d."  The 
patient  hears  subjective  rushing  sounds  on  left  side.  Is  slightly  hysteri- 
cal, and  suffers  from  menstrual  irregularities.  She  gives  no  history  of 
any  traumatism,  no  blow  or  fall,  nor  previous  illness.  Her  mother  and 
father  are  living,  but  of  decided  nervous  temperament ;  paternal  aunt 
and  some  of  mother's  connections  are  insane.  Maternal  grandmother  and 
her  brother  died  of  phthisis.  The  patient  has  had  night-sweats  and  some 
pulmonary  symptoms.     There  is  no  specific  history. 

Upon  a  previous  visit  she  stated  that  there  was  great  formication  in  the 
sole  of  the  right  foot.  She  afterwards  went  to  her  home  in  Vermont, 
when  I  lost  sight  of  her,  but  have  subsequently  heard  of  the  advance  of 
her  symptoms. 

The  tendon  reflex  is  usually  exaggerated  upon  the  paralyzed  side  ;  in 
fact,  I  have  found  it  to  be  the  forerunner  of  a  hemiplegia,  and  it  may  be 
looked  upon  as  a  diagnostic  sign,  or  rather  a  warning,  of  what  may  be 
expected. 

Morbid  Anatomy. — Without  attempting  any  classification,  I  will 
briefly  allude  to  those  forms  of  intra-cranial  growth  most  often  met  with. 
Probably  that  which  is  most  common  is  Tubercle.  Amongst  young  chil- 
dren tubercle  is  found  sometimes  in  masses  of  considerable  size  ;  and,  ac- 
cording to  Wilks,  the  cerebellum  is  its  most  familiar  seat.  It  is  found  as 
a  cheesy  accumulation  of  dirty  green  color,  and  very  rarely  has  the  gray- 
ish appearance  of  the  deposit  been  found  in  other  parts  of  the  body. 
These  masses  are  rather  dry,  and  decidedly  n on- vascular,  and  if  a  collec- 
tion has  been  arrested  in  its  growth  will  be  found  to  be  encysted,  and  may 
be  readily  removed.  If  of  progressive  growth,  the  limits  of  the  deposit 
are  blended  with  the  surrounding  brain-substance,  and  of  a  consistency 
like  cold,  white  glue.  Tuberculous  masses  are  rarely  single,  but  generally 
invade  several  regions  in  the  same  brain,  so  that  it  is  impossible  to  give 
any  very  satisfactory  table  which  will  throw  light  upon  the  question  of 
distribution.^ 

Fox,  in  speaking  of  Jaccoud's  observations,  says  :  "  I  much  prefer  Jac- 
coud's  account  of  these  tubercles.  They  occupy  the  white  and  the  gray 
substance  equally,  and  present  themselves  under  the  form  of  small  iso- 
lated circumscribed  masses,  varying  in  number  from  one  to  twenty,  and 

^  Grasset*  has  classified  brain  tumors :  1.  Those  of  the  embryonic  tissue  (tissu  em- 
bryonnaire).  These  are  the  Sarcomata — a.  Soft  sarcotna;  6.  Sarcoma  nevrogligue 
(glioma) ;  c.  Sarcoma  angiolithique  (or  psammoma).  He  considers  that  the  terms  gli- 
oma and  psammoma  are  improperly  used ;  that  the  first  term  suggests  more  the  con- 
sistence rather  than  the  character  of  the  tumor.  2.  Those  of  the  connective  tissue, 
which  are — a.  Myxoma  ;  b.  Fibroma  ;  c.  Lipoma  ;  d.  Carcinoma  ;  e.  Melanoma.  3. 
Those  of  the  cartilaginous  tissue,  Chondroma.  4.  Those  of  the  osseous  tissue,  Osseoma. 
5.  Those  of  the  ephithelial  tissue,  Papilloma.  6.  Those  of  the  nervous  tissue,  Neuroma. 
7.  Tubercle.  8.  Syphilitic  Tumors.  9.  Parasitic  tumors  (Hydatids).  Aneurism.  10. 
Abscesses. 

*  Maladies  du  Systeme  Nerveux,  Paris  and  Montpellier,  1878,  p.  302. 


212        DISEASES    OF   THE   CEREBRUM    AND    CEREBELLUM. 

seldom  exceeding  the  latter.  Their  volume  is  in  inverse  ratio  to  their 
number.  Pretty  ofien  they  are  the  size  of  a  cherry,  at  other  times  they 
scarcely  exceed  the  size  of  a  grain  of  wheat.  As  to  the  colossal  masses 
which  attain  to  the  magnitude  of  a  hen's  egg,  they  result  from  the  conflu- 
ence and  fusion  of  several  spots  originally  distinct."^ 

They  are  sometimes  separated  from  the  nervous  substance  by  a  sheath 
of  connective  tissue  and  blood  vessels.  In  this  connective  tissue,  which  is 
well  filled  with  vessels,  according  to  Virchow,  ^  the  new  granules  are 
formed,  and  are  impacted  with  the  central  mass,  and  become  cheesy. 
When  the  process  stops,  the  growth  is  found  to  be  surrounded  hj  a  tough 
fibrous  coat,  which  is  sometimes  very  hard,  and  even  calcified  in  old  cases. 

Ogle^  has  reported  a  case  where  the  tuberculous  mass  had  broken  down, 
so  that  it  was  soft  and  pultaceous.  In  the  younger  subjects  tubercle  is 
generally  found  in  other  parts  of  the  body.  It  is  quite  easy  to  mistake 
tuberculous  growths  for  those  of  a  gummatous  nature. 

Cancerous  groxoths  in  the  brain,  which  seem  to  affect  those  of  advanced 
age,  take  much  the  same  form  as  they  do  in  other  parts  of  the  body.  En- 
cephaloid  and  scirrhus  are  the  commoner  forms,  though  melanomata  are 
occasionally  found. 

The  investing  membranes  may  all  be  the  seat  of  cancer,  but  notably 
the  pia  mater  and  the  bony  walls  of  the  cranium  are  its  starting  points. 


Fig.  29. 


Fiff.  30. 


Tubercular  Deposit  about  V 


Sarcoma. 


In  this  case  the  cancerous  mass  grows  inwards,  where  it  meets  less  re- 
sistance, while  cancer  of  the  hrain  itself  grows  outwards.  Cancerous 
masses  are  occasionally  very  large,  and  in  one  of  Russel's  cases  (to  which 
allusion  has  already  been  made)  the  cancerous  mass,  which  occupied  the 
right  parietal  region,  weighed  six  ounces  and  a  half.     These  tumors  pre- 


1  Fox,  op.  cit,,  p.  151. 

»  Cellular  Pathology,  p.  523. 

•'  Articles  in  Br.  and  For.  Med.-Chir.  Keview,  1864  and  1865. 


BEAIN    TUMORS. 


218 


sent  tlie  same  characteristics  they  possess  in  other  regions.  The  encepha- 
loid  variety  is  very  vascular ;  the  scirrhus  not  so  much  so,  and  is  quite 
hard.  The  carcinomatous  growth  presents  the  usual  appearance  of 
cells  contained  in  the  alveoli  of  a  fibrous  network  or  stroma.  It  may  ex- 
ist alone  as  an  intracranial  growth,  or  coexist  with  cancer  of  other  organs. 


Fig.  31. 


Fig.  32. 


Gamma. 


Psammoma. 


The  cancerous  growth  invades  the  cerebral  substance,  though  generally 
the  dura  mater  and  the  other  meninges  may  be  the  parts  at  first 
affected. 

Fig.  33.  Fig.  34. 


Encephaloid. 


Glioma. 


Syphilis  very  often  produces  changes  in  the  contents  of  the  cranium 
which  are  quite  formidable.  Of  diffused  infiltration  I  will  not  speak,  but 
of  those  growths  known  as  gummata,  or  "  gummy  tumors."  The  menin- 
ges and  cortex  cerebri  are  commonly  the  parts  which  favor  the  syphilitic 


214  DISEASES    OF    THE    CEREBRUM    AND   CEREBELLUM. 

deposits,  though  deeper  regions  may  Very  often  be  invaded  by  the  trans- 
lucent reddish-gray  tumors  of  specific  origin.  The  interior  is  sometimes 
jelly-like  and  soft,  and  contains  minute  red  points,  while  the  periphery 
is  hard  and  fibrous.  The  tumor  proper  appears  to  be  separated  from  the 
surrounding  brain  substance  by  this  fibrous  covering,  though  there  is 
always  infiltration  into  the  parts  adjacent.  Syphilitic  growths  are  rarely 
single,  and  I  have  seen  a  number  of  them  in  the  same  brain.  Beneath 
the  microscope  the  tumor  seems  composed  of  round  cells  about  the  size 
of  white  corpuscles,  containing  a  single  nucleus.  These  round  cells  oc- 
cupy the  centre  of  the  mass  while  the  outer-portion  is  composed  of  a  net- 
work of  connective  tissue  containing  irregular  cells.  The  syphilitic 
growth  may  sometimes  be  mistaken  for  that  of  a  tuberculous  nature. 
Niemeyer  has  reminded  us,  however,  "  that  in  syphiloma  the  passage 
from  the  cheesy  centre  to  the  broad,  grayish-white  peripheral  zone  is  very 
gradual,  while  in  infiltrated  growing  tuberculi  these  zones  follow  each 
other  more  closely,  and  in  tubercules  that  can  be  turned  out  they  do 
not  exist."  The  dura  mater  is  very  commonly  the  point  of  origin. 
This  case,  for  the  history  of  which  I  am  indebted  to  Dr.  Ryan,  was 
diagnosed  by  him  during  life.  The  patient  was  in  the  service  of  Dr. 
Mason. 

William  Browning,  set.  32,  native  of  the  United  States,  boatman,  by 
occupation,  married,  was  admitted  to  the  Paralytic  and  Epileptic  Hospi- 
tal of  Black  well's  Island,  on  March  13,  1877. 

The  patient  says  he  has  always  been  a  hard  drinker.  Had  been  a  very 
healthy  man  up  to  seven  years  ago,  when  he  contracted  syphilis,  and  has 
since  that  period  been  subject,  from  time  to  time,  to  outbreaks  of  the  dis- 
ease in  its  tertiary  form.  Two  years  ago  he  had  a  convulsive  attack, 
which  occurred  at  night;  after  which  he  was  out  of  his  mind  for  three 
weeks.  Since  that  time  he  has  been  subject  to  one  or  two  attacks  oc- 
curring every  month.  Since  admission,  the  patient  had  four  epilepti- 
form fits,  characterized  by  clonic  spasms,  a  confused  and  perturbed  con- 
dition of  the  mental  faculties,  but  no  distinct  loss  of  consciousness.  A 
premonitory  feeling  of  great  terror  was  always  experienced  about  ten  or 
fifteen  minutes  prior  to  the  convulsion,  and  this  sense  of  dread  remained 
for  some  time  after  each  fit ;  these  seizures  being  always  followed  by  in- 
tense headdche  and  debility,  which  generally  lasted  for  several  days. 
The  patient's  sight  has  failed  greatly  for  the  last  year  ;  unfortunately 
no  ophthalmoscopic  examination  was  made.  His  memory,  he  said,  wis 
getting  very  much  impaired,  and  any  mental  occupation  caused  violent 
headache. 

April  28,  the  date  of  his  last  attack,  he  had  been  in  bed,  complaining 
of  sevei'e  pains  in  the  head,  referred  chiefly  to  the  frontal  region  of  the 
right  side.  This  pain  was  always  greater  at  night;  the  patient  com- 
plained of  no  other  trouble,  with  the  exception  of  great  weakness  and 
anorexia,  until  about  May  5,  when  slight  paralysis  of  the  muscles  on  the 
right  side  of  the  face  was  noticed,  especially  of  the  orbicularis  palpe- 
brarum There  was  also  a  distinct  loss  of  muscular  power  iu  the  left 
upper  extremity,  which  was  colder  to  the  touch  than  the  right,  and  the 
pulse  of  the  affected  limb  was  feeble  and  compressible.  On  May  14  the 
patient  became  somewhat  delirious,  and  remained  so  till  the  time  of  his 


BRAIN    TUMORS.  215 

death.  On  the  17th  he  began  to  cough,  and  expectorated  a  great  quan- 
tity of  sero-mucous  fluid.  Mucous  and  subcrepitant  rales  were  heard  over 
all  the  anterior  surface  of  both  lungs ;  a  change  in  the  pulse  and  tem- 
perature, which  had  previously  remained  normal,  was  now  noticed ;  the 
former  being  130,  and  the  temperature  103°.  Herpes  appeared  on  the 
forehead  and  lips.  On  the  morning  of  the  18th,  patient  was  in  a  semi- 
comatose condition.  Pulse  160,  temperature  104°.  He  died  at  2  o'clock 
P.  M.  of  same  day. 

Autopsy  twenty  four  hours  after  death.  Rigor  mortis  passing  off;  body 
somewhat  emaciated  ;  suggillation  of  posterior  portion  of  body.  Old 
cicatrices  (large)  over  the  left  tibia,  also  several  smaller  ones  scattered 
over  exterior  and  upper  portions  of  body. 

Head  :  The  dura  mater  is  markedly  thickened  over  portion  of  the 
parietal  bone  of  right  side  adjacent  to  temporal  bone,  and  is  also  adhe- 
rent to  a  tumor  beneath  in  the  brain-substance.  On  three  points  on  inner 
surface  of  parietal  bone  (right)  are  spots  of  necrosis,  the  size  of  a  dime, 
which  involve  the  inner  table.  The  dura  can  easily  be  separated  from 
the  bone,  but  not  from  the  surface  of  the  tumor.  This  tumor  is  three 
inches  from  above  downwards,  and  two  and  one-half  inches  from  before 
backwards.  It  is  firm,  and  of  a  yellowish  color.  The  brain-substance 
directly  beneath  it  is  the  seat  of  softening  (inflam.),  while  beyond  this 
point,  and  extending  in  a  direct  line  to  optic  thalamus  of  right  side,  the 
brain-substance  is  softened  and  diffused.  The  outer  border  of  posterior 
portion  of  optic  thalamus  is  in  the  same  condition,  while  the  meninges 
and  vessels  are  normal. 

Thorax :  Lungs.  Bands  of  adhesion  on  right  side,  and  a  few  at  apex 
of  left.  In  the  lower  lobe  of  right  are  numerous  spots  of  lobular  pneu- 
monia in  gray  stage.  On  anterior  margin  of  right  lung  some  emphysema, 
and  also  at  apex  of  left  lung.  •  Otherwise  both  lungs  show  marked  hypo- 
static congestion  and  oedema. 

Heart  soft  and  flabby.     Seat  of  post-mortem  decomposition. 

Abdomen  :  Liver  increased  in  length ;  evidences  of  peri-hepatitis.  On 
surface  of  liver  are  seen  several  old  cicatrices,  which  dip  down  into  liver 
substance.  The  parenchyma  in  patches  is  softened  and  fatty  (syphilitic 
liver?). 

Spleen  increased  in  size.  Capsules  thickened  in  patches  ;  parenchyma 
difiluent. 

Kidneys  about  normal  size.  On  stripping  capsule  it  brings  away  por- 
tion of  kidney  tissue.  Surface  appears  granular,  and  in  some  points 
shows  lobulation.  Section  shows  tubules  swollen,  and  of  yellowish  color. 
There  appear  to  be  about  normal  relations  between  cortical  and  pyramidal 
portions.     Pelvis  and  ureters  normal. 

Bladder,  stomach,  and  intestines  normal. 

Parasitic  Growths  (Hydatids  and  Cysticerci). — Hydatids  are  always 
contained  in  a  delicate  cyst  (except  when  they  occupy  the  lateral  ven- 
tricles), and  there  may  be  several  in  the  same  capsule.  The  cysts  are  of 
variable  size,  and  sometimes  attain  the  magnitude  of  a  fair-sized  orange 
(Reynolds).  They  are  occasionally  very  large,  and  the  centre  of  either 
hemisphere  seems  to  be  their  common  site.  Cysticerci,  which  are  very 
small,  and  are  sometimes  contained  in  cysts,  rarely  exceed  the  size  of  a 
large  marble,  but  are,  however,  more  often  found  uninvested,  and  they 


216        DISEASES    OF     THE    CEREBRUM    AND    CEREBELLUM. 

may  be  from  one  to  several  hundred  in  number.  They  prefer  the  cor- 
tex, and  are  often  found  beneath  the  pia  mater.  It  seems  to  me  that 
these  would  be  among  the  most  interesting  cases  for  the  observation  of 
irritation  of  the  motor  centres ;  usually,  however,  there  are  very  slight 
indications  of  their  presence.  In  patients  who  suffer  from  cysticerci  in 
the  brain  the  diagnosis  may  sometimes  be  made  by  the  presence  of  por- 
tions of  tsenia  in  the  stools,  or  a  cysticercus  in  the  anterior  chamber  of 
the  lens,  which  was  the  case  in  the  example  reported  by  Pollock.^ 

Romberg,  while  making  some  experiments,  found  that  the  existence  of 
cysticerci  in  the  cerebelli  of  several  sheep  accounted  for  the  peculiar  roll- 
ing convulsions  that  he  had  observed. 

Cysts,  which  are  not  the  secondary  result  of  softening  or  hemorrhagic 
disease,  are  very  rare,  and  are  not  usually  larger  than  pin-heads. 

Gliomatn,  which  are  directly  formed  from  the  connective  tissue,  are 
more  common  in  the  posterior  lobes  and  in  the  cerebellum  than  in  any 
other  locality.     The  soft  and  Jinn  are  the  two  varieties. 

Amyloid  bodies,  connective  tissue  cells  and  vessels  are  found  to  com- 
pose these  tumors,  which  may  sometimes  attain  a  diameter  of  several 
inches.  The  peri-vascular  spaces  are  filled  with  adventitious  matter,  and 
the  calibre  of  the  vessels  is  very  much  reduced.  These  growths  may 
undergo  fatty  degeneration  or  absorption.  The  hard  varieties,  I  think, 
predominate,  and  they  are  very  easy  to  recognise. 

Papillomata,  both  of  the  vessels  and  meninges,  are  not  uncommon. 

Myxomata,  which  Jaccoud  describes  as  having  their  source  of  origin 
from  the  spheno-occipital  suture,  are  quite  rare,  as  are  Lipomata.  The 
former  are  usually  of  large  size,  have  a  gelatinous  appearance,  and  at 
times  are  cloudy.  The  latter  consist  of  large  cells  filled  with  fat,  and  are 
transparent  and  shining. 

Sarcomata  may  be  met  with  as  soft  masses,  which  contain  "  fusiform 
bodies,  nuclei,  and  vessels,"  or  else  round  cells  closely  packed.  They 
are  lobulated,  and,  when  cut,  present  a  j^inkish-gray  and  softened  sur- 
face, and  sometimes  contain  central  fluid.  The  soft  sarcoma,  according 
to  Grasset.  is  found  among  young  children  in  the  deeper  parts  of  the 
brain,  and  i-emains  dormant  for  some  time,  not  giving  rise  to  any  symp- 
toms, the  cells  being  usually  round  ("  globo-cellulaire ").  With 
fatty  degeneration  the  tumor  may  undergo  a  change,  so  that  it 
resembles  the  yellow  plates  in  cerebral  softening.  It  usually  has  a  sur- 
rounding vascular  network,  and  is  easily  separated  from  the  brain-sub- 
stance. 

Fibrous  tumors  are  quite  rare,  but  are  sometimes  met  with.  Lebert  has 
seen,  in  one  case,  seventeen  small  fibrous  tumors  upon  the  epeudyma  of 
the  lateral  ventricle,  varying  from  the  size  of  a  pea  to  that  of  a  small 
cherry-stone.     These  tumors  are  of  a  white  color  and  globular  shape, 

1  Wiener  Med.  Pre?se.,  47,  1878. 


BRAIN    TUMORS.  217 

and  they  are  separated  from  the  healthy  brain-tissue  by  a  space  in  which 
the  vessels  are  enlarged.  They  are  easily  enucleated,  and  quite  hard  and 
dense.^ 

Aneurisms. — One  of  the  most  interesting  and  important  forms  of  intra- 
cranial growths  are  those  of  a  vascular  character.  I  have  taken  occa- 
sion to  refer  to  the  smaller  aneurisms  described  by  Bouchard  and  Char- 
cot, the  so-called  miliary  aneurisms,  which  are  of  minute  size ;  but  large 
aneurisms,  arising  from  such  arteries  as  the  middle,  anterior  and  posterior 
cerebral,  basilar,  and  communicating  arteries,  may  be  even  an  inch  in 
diameter.  These,  with  miliary  aneurisms  of  small  size,  are  generally 
found  to  coexist  in  the  brain.  Gouguenheim^  and  others  have  found  that 
aneurism  of  the  basilar  artery  was  much  more  common  than  any  other 
form.  It  is  rare,  however,  that  the  disease  can  be  diagnosed  during  life, 
and  but  two  or  three  cases  have  been  reported  where  their  presence  was 
recognized  by  symptoms,  and  afterwards  verified  by  an  autopsy.  One  of 
these  cases  was  reported  by  Coe,^  another  by  Jonathan  Hutchinson,*  and 
a  third  by  Humble ;  ^  in  this  case,  however,  the  diagnosis  was  made  by 
auscultation. 

Occasional  intracranial  growths  are  the  psammomata  which  are  found 
as  sandy  little  bodies  scattered  overed  the  dura  mater,  and  have  a  cal- 
careous formation,  feel  gritty  when  rubbed  beneath  the  fingers,  and  may 
be  crumbled.  Examined  microscopically  with  a  low  power  they  may  be 
found  to  consist  of  small,  compact,  round  bodies,  imbedded  usually  in 
the  dura  mater. 

Cholesteatoma,  or  pearly  tumors,  which  are  composed  chiefly  of  choles- 
terine,  stearine,  and  degenerated  epithelium  contained  in  an  investing 
membrane,  are  occasionally  present  in  the  brain.  The  latter  growths 
are  generally  found  attacked  to  the  meninges  or  cranial  bones,  and  are 
nearly  always  superficial. 

The  literature  of  intracranial  bony  growths  contains  much  that  is  in- 
teresting. One  case  reported  by  Vulpian  in  the  Archives  de  Physiologie 
was  remarkable  for  the  slow  development  of  an  exostosis  from  the  tem- 
poral bone,  which  completely  penetrated  the  Gasserian  ganglia  on  the 
right  side.  Beyond  neuralgia  of  a  severe  character,  no  other  symptoms 
were  expressed.  I  have  seen  many  of  these  bony  growths,  some  of 
them  even  several  inches  in  length,  which  had  existed  for  years  without 
any  mischief  being  produced.  In  slow  growths  there  seems  to  be  an  ac- 
commodation of  the  brain  so  that  the  pressure  is  rarely  injurious,  and  it 
is  generally  not  till  the  exostosis  attains  some  size,  and  atrophy  or  soft- 
ening takes  place,  that  bad  symptoms  make  their  appearance. 


^  Anat.  Path.,  vol.  ii.  p.  71. 

^  Gouguenheim,  Des  Tiiraeurs  Anevrysmales,  etc,  Paris,  1866,  and  also  consult 
Smith,  Dub.  Jour,  of  Med.  Sci.,  Nov.  1870. 

*  Quoted  by  Holmes. 

*  Transactions  of  the  Clinical  Society,  vol.  viii.,  1875,  p.  127. 
5  Lancet,  Oct.  2,  1875,  p.  489. 


218         DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

A  case  which  was  under  the  care  of  Dr.  Janeway  at  the  Epileptic 
Hospital  is  one  of  the  most  remarkable  of  which  I  have  ever  heard,  and 
I  append  his  very  valuable  record  of  the  post-moi'tem  examination. 

A.  T.,  aged  42  years;  widow;  domestic.  Admitted  to  Hospital  De- 
cember 31,  1872.  Patient  says  that  fourteen  mouths  ago,  as  she  was 
crossing  the  ferry,  she  fell  down,  and  heard  people  say  that  some  one  had 
had  a  fit.  When  she  came  to,  she  found  that  she  herself  had  had  a 
convulsion.  During  the  attack  she  was  perfectly  conscious  of  all  that 
passed  about  her,  aud,  on  arising  and  attempting  to  tie  her  bonnet  strings, 
she  found  that  she  could  not  do  so  on  account  of  what  she  says  was 
numbness  of  the  hands  or  arms. 

Api'il  29,  1874.  For  the  past  five  days  she  has  been  very  dizzy,  and 
has  had  headache,  and  pain  in  the  left  side  under  the  breast. 

SOfh.    Is  in  bed.     Says  "  her  back  feels  as  if  it  was  breaking  in  two." 

May  1.  Is  quite  weak.  Can  move  her  left  leg  somewhat,  but  not  her 
left  arm  ;  her  emotions  are  easily  excited  ;  pulse  weak  ;  temperature, 
10H°. 

Zrd.  She  lies  with  eyes  half  parted,  and  does  not  open  them  fully 
when  spoken  to.  Pupils  normal  and  respond  to  light.  Answers  ques- 
tions in  a  slow,  whining  tone,  and  with  seeming  difficulty.  Does  not 
draw  up  her  legs  when  told,  but  they  respond  to  reflex  irritation.  The 
severe  pain  in  her  back  still  continues,  and  she  has  some  pain  under  left 
breast.  Pain  on  pressure  in  the  right  iliac  region.  Bowels  free ;  urine 
normal;  respiration  normal;  temperature  100°.  Is  somewhat  stupid; 
has  great  pain  in  back  of  her  head ;  eyes  half  closed  ;  conjunctiva  not 
very  sensitive ;  passes  urine  and  feces  in  bed. 

4th.  Sleeping;  feces  of  brown  color;  urine  passed  in  bed;  respiration, 
28;  pulse,  88,  Feces  and  urine  passed  in  bed  during  afternoon  ;  tongue 
dry  and  coated  brown.  Only  partially  protruded  tongue  when  told  to. 
Eyes  half  closed;  seems  brighter;  respiration,  36;  pulse,  100;  tempera- 
ture, 102°. 

dth.  Complains  of  pain  in  abdomen  ;  bowels  did  not  move  last  night; 
cries  when  spoken  to  ;  pain  in  back  lighter,  but  in  head  is  sharp.  Pulse, 
88;  temperature,  100°  at  11  o'clock,  A.  M,  Urine  highly  colored ;  no 
albumen. 

10^^.  Still  pain  at  base  of  skull.     Temperature,  101 4  °- 

12th.  Temperature,  1001°.  12  M.  Temperature,  99°;  headache  not 
so  severe. 

June  2,  No  headache  ;  cries  when  spoken  to. 

6th.  Headache  not  so  severe  ;  pain  in  her  back. 

10th.  Lies  with  head  turned  to  left.  Complains  of  pain  when  position 
of  head  is  changed.     Headache  is  relieved  by  bromide  of  ammonium. 

19th.  Complains  of  no  pain.  There  appears  complete  muscular  relax- 
ation.    Cannot  speak  without  crying. 

20th.  Patient  is  rapidly  failing.  Temperature,  103|°;  pulse,  too  rapid 
to  count;  respiration  very  quick;  conjunctiva  insensible;  pupils  respond 
slowly  to  light. 

2lst.  This  morning  about  the  same  ;  can  swallow  wine.  Patient  sank 
gradually  during  afternoon,  and  died  at  4.30. 

Podmortem  18  hours  after  death. — Heart,  liver,  lungs,  spleen,  and 
kidneys  normal.  An  abscess  found  in  right  Fallopian  tube  containing 
about  3ij  of  pus.     Rigor  mortis  not  well  marked. 


BRAIN    TUMORS.  219 

Skull. — On  removing  skullcap  an  outgrowth  of  bone  is  noticeable  on 
the  right  side,  near  the  central  line,  just  posterior  to  the  groove  for  the 
middle  meningeal  artery.  The  growth  is  nearly  two  inches  long,  and 
one  inch  wide;  raised  about  i  of  an  inch  from  internal  surface.  The  dura 
mater  was  pretty  firmly  attached  at  this  place,  and  little  pieces  were  left 
attached  to  the  exostosis.  There  is  another  bony  projection  (small)  just 
back  of  the  middle  meningeal  artery,  at  the  inferior  angle  of  the  parietal 
bone.  Otherwise  interior  of  skull  appears  normal.  The  lowest  first  (1st) 
is  situated  just  anterior  to  the  fissure  of  Sylvius,  f  inch  below  posteriorly, 
and  I  inch  from  above  downwards.  Elevation,  Ifths  of  an  inch.  This 
has  produced  a  corresponding  depression  and  flattening  of  the  commence- 
ment of  the  lower  end  of  the  transverse  convolution  of  the  anterior  lobe. 
Two  smaller  ones  are  situated  one  just  \  of  an  inch  above  it,  the  other  ^ 
inch  above,  and  about  i  anteriorly.  They  are  nearly  half  an  inch  apart, 
the  posterior  being  the  longer,  and  about  A  of  an  inch  in  diameter.  Ele- 
vation, tV  inch. 

Around  the  first  large  tumor  three  small  ones  exist ;  the  second  small 
one  is  about  one-third  of  the  size  of  the  first.  A  bridge  of  new  formation 
connects  this  with  the  two  already  described.  At  the  point  of  the  large 
exostosis,  a  number  of  tumors  spring  forth  from  under  surface  of  the  dura 
mater,  close  to  one  another,  averaging  If  inch  in  diameter.  One  of  these 
tumors  is  quite  large,  and  is  sunk  in  a  depression  in  the  brain  ;  the  depth 
is  I  of  an  inch,  and  it  is  an  inch  long  and  broad.  The  brain-tissue  around 
this  is  in  a  state  of  pulpy  softening.  The  diameter  of  the  softened  part 
of  brain  is  two  inches,  and  nearly  reaches  the  longitudinal  fissure,  ex- 
tending two  inches  downwards  to  within  two  inches  of  anterior  border 
of  the  brain.  The  falx  throughout  its  extent  is  the  site  of  new  forma- 
tions, some  projecting  on  the  right,  others  on  the  left ;  one  very  large  one 
in  front,  which  is  1^  inch  in  length,  and  has  an  elevation  of  Ifths  of  an 
inch  ;  and  another  which  dips  into  a  depression  in  the  anterior  lobe  of 
left  side. 

The  pia  mater  covering  both  hemispheres  is  markedly  congested.  Tu- 
mors are  firm,  white,  and  yield  only  a  thin  serous  fluid  on  scraping. 

Diagnosis. — It  is  a  difficult  matter,  when  we  consider  the  great  vari- 
ety and  irregularity  in  the  appearance  of  symptoms,  to  make  always  a 
correct  diagnosis.  This  branch  of  neurology  is  undoubtedly  the  most 
puzzling,  and  I  am  inclined  to  differ  from  those  persons  who  consider  it 
possible  to  determine  in  the  majority  of  cases  the  exact  location  of  a  cere- 
bral growth.  The  fact  that  brain-tumors  are  very  often  multiple,  and 
that  secondary  lesions  are  produced,  is  enough  to  cool  the  ardor  of  the 
most  enthusiastic  diaguostician.  It  is  possible,  however,  to  sometimes 
make  a  very  close  diagnosis. 

"We  are  likely  to  mistake  symptoms  of  the  disease  under  consideration 
for  those  of  diseases  of  an  organic  character.  The  common  lesions 
involving  a  plugging  or  rupture  of  the  cerebral  arteries  of  the  brain 
may  give  rise  to  manifestations  much  like  those  produced  by  intracranial 
growths. 

Paralysis,  which  is  as  we  know  an  almost  constant  symptom  of  such 
troubles,  differs  from  that  of  cerebral  tumor,  not  only  for  the  reason  I 
have  stated,  viz. :  that  there  are  often  local  epileptoid  symptoms  in  con- 


220  DISEASES   OF   THE   CEREBRUM   AND    CEREBELLUM. 

nectiou  therewith,  but  because  the  appearance  of  secondary  contractures 
in  the  paralyzed  limbs  is  rare.  I  have  found  an  exaggerated  tendinous 
reflex  in  the  subject  of  cerebral  tumor,  but  it  was  never  so  general  as  in 
the  other  cases,  and  not  attended  by  spastic  rigidity.  Then,  too,  the 
paralytic  phenomena  prefer  local  groups  of  muscles,  notably  those  of  the 
face,  while  hemiplegic  disorders  are  peculiar  to  cerebral  hemorrhage,  em- 
bolism, and  thrombosis.  Sudden  paralysis  is  rare,  though  it  may  occur 
from  a  complicating  morbid  process  ;  but  it  is  not  uncommon  to  find  a 
disappearance  and  recurrence.  Cerebral  tumor  is  rarely  preceded  by 
warning  symptoms  or  any  adequate  cause,  except  it  may  be  blows  upon 
the  head,  tuberculosis,  or  syphilis,  but  there  are  many  cases  with  no  pre- 
vious history  of  any  kind.  This  history  of  causes  is  important  to  bear  in 
mind ;  for,  whether  there  be  inflammation  either  of  an  insignificant  kind 
as  regards  violence,  or  one  of  an  acute  nature  resulting  in  abscess,  a  his- 
tory of  sunstroke,  over-work,  alcoholism,  or  aural  disease,  may  be  detected. 

Several  general  diseases  may  occasionally  simulate  cerebral  tumor, — 
among  them  urcemia,  narcotic  poisoning,  heart  disease,  or  even  hysteria  ; 
but  it  must  not  be  forgotten  that  hysterical  symptoms  are  not  rare  accom- 
paniments of  organic  cerebral  diseases,  and  often  of  tumor,  so  that  such 
cases  are  not  always  the  subjects  of  an  easy  diagnosis. 

Localized  pain  and  convulsions,  with  optic  neuritis,  cranial  palsies,  and 
vomiting,  suggest  very  strongly  the  probability  of  tumor. 

The  localization  of  cerebral  tumors  has  received  very  extended  con- 
sideration during  the  past  few  years.  In  the  many  cases  collected  by 
Jackson  we  are  enabled  to  make  a  much  closer  diagnosis  than  before  his 
excellent  investigations  were  presented.  Ogle's  large  number  of  cases 
are  more  of  interest  in  the  light  of  morbid  anatomy,  and  as  they  are 
several  hundred  in  number,  almost  every  variety  of  formation  is  to  be 
found.  Quite  recently,  an  excellent  article  by  Petrina,  of  Prague,^  has 
appeared.  His  directions  for  localization  are  so  complete  that  I  think  it 
wise  to  present  them,  especially  as  they  are  based  upon  a  number  of  cases. 

I.  Tumors  of  the  Convexity. — Clonic  spasms  limited  to  single  groups  of 
muscles  on  the  side  of  the  body  opposite  to  that  of  the  tumor ;  no  loss  of 
consciousness;  incomplete  hemiplegia,  constant  headache,  decided  vertigo, 
nervous  irritability;  amblyopia  and  disturbances  of  hearing;  circum- 
scribed aflection  of  sensibility.  The  localization  of  circumscribed  motorial 
disorders  is  not  definite,  and  can  be  only  limited  at  present  to  the  region 
of  the  anterior  and  posterior  central  convolutions. 

II.  Tumors  of  the  Anterior  Lobes. — Frontal  headache;  the  intellectual 
sphere  being  involved  (?.  A.  McL-  H.)  there  will  be  often  psychical  dis- 
turbances, with  chorea ;  paresis  or  hemiplegia  (the  former  more  fre- 
quently) ;  no  disorders  of  sensibility  ;  general  convulsions  with  loss  of 
consciousness  are  rare,  except  when  there  is  deep  pressure;  visual  disturb- 
ance and  deafness,  with  anosmia. 

1  Vierteljahrsschrift  fuer  di  prakt.  Heilkunde,  cxxxiii.  1.  2.  Abstract  in  Journal 
of  Mental  and  Nervous  Diseases. 


BEAIN    TUMORS.  221 

III.  Tumors  of  Parietal  Lobes. — Hemiplegia  on  opposite  side  preceded 
frequently  by  apoplectic  attacks ;  aphasia  very  frequent  when  tumor  is 
large  enough  to  compress  the  third  frontal  convolution  ;  general  convul- 
sions with  large  tumors ;  disorder  of  special  sense,  except  vision,  quite 
rare;  impairment  of  cutaneous  sensibility  common;  frontal  headache. 

IV.  Tumors  of  the  Occipital  Lobes. — But  one  of  Petrina's  cases  pre- 
sented opposite  sided  paralysis  with  paralysis  of  the  third  nerve  on  the 
same  side ;  disorders  of  intelligence ;  convulsions,  involvement  of  organs 
of  special  sense,  cutaneous  derangements  of  sensibility  are  mentioned 
by  Rosenthal  and  others  as  pathognomonic ;  but  are  not  observed  by 
Petrina, 

V.  Tumors  of  the  Motor  Ganglia. — Hemiplegia  on  opposite  side,  with 
loss  of  consciousness  and  frequent  convulsions  ;  profound  cutaneous  anaes- 
thesia when  the  internal  capsule  is  destroyed  ;  sometimes  aphasia  ;  corpus 
striatum ;  complete  hemiplegia  with  loss  of  consciousness  and  convulsions ; 
psychic  disorders  and  irritative  motor  phenomena,  such  as  tremor  and 
choreoid  movements  ;  disorders  of  organs  of  special  sense  are  rare,  with 
the  exception  of  amblyopia. 

VI.  Tumors  of  Optic  Thalamus. — Extensive  motorial  symptoms  are  not 
constant,  and  general  convulsions  or  disorders  of  sensibility  are  rare. 
"  According  as  the  tumor  affects  more  the  bundles  of  fibres  going  to  the 
optic  tracts  of  those  branching  out  from  the  cerebral  peduncle,  we  have 
sometimes  predominating  paralytic  phenomena  in  the  optic  nerve,  altera- 
tions of  the  pupil  and  disturbances  of  the  innervation  of  the  ocular  mus- 
cles (nystagmus,  exophthalmos)  ;  sometimes,  again,  there  are  the  most 
remarkable  vaso-motor  anomalies  of  circulation  (striking  alterations  of 
temperature,  and  cyanosis,  or  circumscribed  redness),  as  the  chief  morbid 
symptoms.  Pronounced  disorders  of  speech  (retarded  speech)  and  of  the 
intelligence  are  symptomatic  only  of  quite  extensive  tumors  in  the  thala- 
mus ;  decided  paralytic  phenomena  are  likewise  characteristic  of  simulta- 
neous destruction  of  the  peduncular  fibres,  or  of  one  of  the  motor  gan- 

glia." 

VII.  Tumors  in  or  about  the  Pituitary  Body. — Somnolence,  mental  weak- 
ness, or  apathy;  slowness  of  speech.  Amblyopia  and  amaurosis  are 
common,  as  well  as  disorders  of  other  organs  of  special  sense.  Rosenthal 
demonstrated  that  diabetes  is  an  important  complication  of  tumor  in  this 
region. 

VIII.  Tumors  of  the  Peduncles  of  the  Cerebrum. —  Vaso-motor  disor- 
ders and  anomalies  of  temperature ;  early  paralysis  of  the  third  nerve  on 
the  same  side,  as  tremor,  occasional  vesical  paralysis;  opposite  hemiplegia 
with  sensory  disorders;  intelligence  unimpaired;  optic  nerve  often  in- 
volved ;  involuntary  movements  of  limbs  on  side  opposite  to  tumor. 

IX.  Tumors  of  the  Crus  Cerebelli. — Intense  headache  and  vertigo,  in- 
voluntary lateral  decubitus,  rotation  of  body,  one-sided  deviation  of  axis 
of  vision,  reeling  gait,  and  tendency  to  fall;  commonly  disturbances  of 
organs  of  special  sense.     (  Vide  Caton's  Case,  A.  McL.  H.) 

X.  Tumors  of   Cerebellum. — Headache   quite  intense,  and  limited  to 


222         DISEASES    OF    THE    CEREBRUM    AKD    CEREBELLUM. 

sub-occipital  region,  vertigo,  reeling  gait,  disorders  of  co-ordination ; 
paresis  of  opposite  side  of  body ;  convergent  strabismus,  diminished  elec- 
tro-muscular contractility  on  sound  side  of  head. 

XI.  Tumors  of  Pons. — Cross  hemiplegia  ;  ocular  paralysis  (convergent 
strabismus),  lingual  paralysis  ;  cutaneous  anaesthesia,  double  or  single,  dys- 
phagia ;  disorders  of  special  senses ;  facial  nerve  involved ;  crossed  sen- 
sory troubles;  vaso-motor  disturbances;  vertigo;  increased  electro-mus- 
cular contractility  of  parts  supplied  by  the  seventh  nerve  to  galvanic 
current,  but  not  to  faradic  current. 

Greisinger  has  written  quite  fully  upon  the  diagnosis  of  the  character 
of  the  growth.  He  considered  that  convulsion  with  psychical  disturbance, 
but  no  paralysis,  pointed  to  the  presence  of  cysticerci,  because  these  para- 
sites infest  the  uppermost  layers  of  the  cortex  cerebri. 

In  one  of  Jackson's^  cases  (No.  13)  the  signs  of  an  old  iritis  enabled 
him  to  make  a  diagnosis  of  a  gumma.  Other  marks  of  syphilitic  disor- 
der may  be  taken  into  account.  Nodes,  old  scars,  eruptions  of  a  tertiary 
character,  and  alopecia,  as  well  as  numerous  unmistakable  symptoms, 
such  as  rheumatism,  night-sweats,  etc.,  are  confirming  points  in  diagnosis. 
Aneurism,  which  is  rare  in  early  life,  may  be  suggested  by  veriigo  and 
subjective  noises  heard  by  the  patient.  In  the  case  reported  by  Humble 
a  diagnosis  was  made  by  the  stethoscope.  Cancerous  tumors  are  very  dif- 
ficult to  diagnose,  the  age  of  the  patient  and  the  cachectic  signs  being  our 
only  guide,  aud  we  are  left  absolutely  in  the  dark  in  regard  to  gliomatous 
and  other  non-diathelic  tumors,  although  some  of  the  German  writers 
suggest  that  a  history  of  injury  generally  precedes  the  first  named.  Tu- 
bercle may  be  suspected  after  a  careful  inquiry  in  regard  to  the  patient's  an- 
tecedents, and  the  recognition  of  the  physical  signs  of  deposit  in  the  lungs. 
Parasitic  tumors  are  generally  attended  by  mental  decay,  and  it  has 
been  stated  that  epileptiform  attacks  are  the  first  symptoms  of  such  trouble. 

Prognosis. — Cancerous  tumors  prove  fatal  in  from  two  or  three  months 
to  a  year,  while  syphilitic  tumors  are  occasionally  retarded  in  growth,  arid 
the  jjatient  may  ultimately  recover  under  energetic  treatment,  though 
when  left  alone  they  rapidly  increase  in  size.  I  do  not  believe  in  the 
spontaneous  cure  of  aneurismal  tumors,  and  feel  disposed  to  consider  any 
cases  of  sudden  recovery  as  anomalous.  Holmes  says  in  this  connection: 
"  We  know  nothing  at  present  of  the  diagnosis  of  intracranial  aneurism, 
so  that  no  treatment  can  as  yet  be  directed  specially  to  it.  And,  looking 
at  the  very  free  intercommunication  of  the  four  large  trunks  which  nour- 
ish the  brain,  it  seems  unlikely  that  surgical  measures  directed  to  anyone 
of  them  would  procure  the  consolidation  of  an  aneurism  situated  ou  one 
of  its  main  branches."  The  progress  of  non-diathetic  growths  is  very 
slow,  and  the  patient  may  live  for  many  years,  and  finally  die  of  some 
other  disease.  Gliomatous  tumors  are  perhaps  less  formidable  than  are 
others,  but  after  all  more  depends  upon  the  site  of  the  growth  than  its 
size  aud  character.     Death  is  preceded  in  most  instances  by  coma. 

*  Medical  Times  and  Gazette,  August  1,  1874. 


DISEASES    OF    THE    CEREBELLUM.  223 

Obernier  refers  to  the  increase  in  growth  of  cerebral  tumors  following 
the  excessive  indulgence  in  alcoholic  drink,  and  believes  that  a  debauch 
may  give  rise  to  violent  meningitis  and  death. 

Treatment. — It  has  been  my  practice  in  every  case  to  place  the  pa- 
tient upon  an  anti-syphilitic  course  of  treatment.  The  iodide,  in  increas- 
ing doses,  until  a  very  large  quantity  is  taken  during  the  day,  will  some- 
times effect  a  cure.  I  have  given  mercury  also,  but  cannot  speak  so  fa- 
vorably of  its  virtues.  If  the  pain  is  excessive,  I  use  the  ice-bag,  as  re- 
commended by  Jackson,  or  the  cold  water  coil  of  Chamberlain,  and  find 
that  they  give  great  relief.  Hypodermic  injections  are  very  useful,  and 
hyoscyamus  and  belladonna  also  do  good.  Galvanism  I  believe  to  be 
useless.  Ligature  of  the  carotid  has  been  employed  by  Coe  for  aneuris- 
mal  tumors,  and  although  it  was  successful  in  the  case  he  reports,  I  am 
inclined  to  think  it  is  not  only  a  dangerous  but  an  uncertain  measure.  Hum- 
ble, in  commenting  upon  this  and  other  cases,  speaks  of  Balfour's  plan  of 
treatment,  which  consists  in  the  administration  of  large  doses  of  the  iodide  of 
potassium.  One  of  the  chief  indications  in  the  treatment  of  cerebral  tumor 
is  the  administration  of  remedies,  and  agencies  that  shall  tend  to  diminish 
the  excessive  termination  of  blood  toward  the  brain,  thus  cutting  oif  the 
supply  of  nourishment  as  far  as  possible.  A  comparatively  ansemic  state 
of  the  brain  is  better  than  the  reverse.  We  should  caution  our  patient  in 
regard  to  the  use  of  stimulants,  and  should  enjoin  early  hours,  abstinence 
from  brain  work  and  rest.  Purgatives  and  local  derivatives  do  much 
good  in  certain  cases. 

DISEASES  OF  THE  CEREBELLUM. 

The  cerebellum  like  the  anterior  brain,  is  apt  to  be  the  seat  of  certain 
familiar  morbid  processes,  and  among  the  more  common  are  hemorrhage, 
tumor,  softening,  atrophy  and  the  like.  Tumor,  is  perhaps  most  readily 
diagnosed  on  account  of  the  slow  development  of  symptoms,  and  a  cer- 
tain degree  of  uniformity  in  their  appearance,  but  such  is  by  no  means 
the  invariable  rule. 

General  Symptoms  of  Cerebellar  Disease. — The  most  conspicuous  evidence 
of  trouble  is  shown  in  an  uneven  exercise  of  motor  power,  and  this  has 
been  recognized  for  many  years  by  all  who  have  had  occasion  to  examine 
cases  of  this  disease.  The  defective  co-ordination  is  chiefly  shown  in 
grand  movements,  such  as  walking,  and  in  certain  cases  there  is  a  ten- 
dency upon  the  part  of  the  patient  to  fall  backward,  while  in  fact  in 
nearly  all  there  is  a  reeling,  unsteady  walk,  that  by  Hughlings  Jackson 
has  been  compared  to  the  method  of  progression  of  druukards. 

This  is  increased  when  the  eyes  are  closed,  and  just  as  in  some  forms  of 
other  disease,  such  for  instance,  as  posterior  spinal  sclerosis,  the  patient 
cannot  preserve  his  balance  when  he  has  no  support.  Such  troubles 
result  probably  from  a  certain  impairment  of  the  harmony  of  the  visual 
apparatus  and  the  co-ordinatiug  centres,  and  this  in  turn  undoubtedly  arises 
from  derangement  of  the  existing  relations'  between  the  cerebellar  fibres 


224         DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

and  the  optic  lobes.  The  patients  reel  and  walk  with  feet  spread  widely 
apart.  I  have  repeatedly  detected  an  increase  in  awkwardness  when  the 
person  looks  up,  and  when  the  individual  makes  any  sudden  and  rapid 
forward  motion,  he  often  staggers  and  falls  backwards.  There  is  rarely 
paralysis  in  any  form  of  cerebellar  disease  until  the  end,  and  then  it  is 
due  to  complication  of  other  parts,  and  is  accompanied  by  rigidity  and 
local  spasms.  Jackson  has  repeatedly  insisted  upon  the  importance  of  a 
symptom  of  cerebellar  disease,  and  I  am  able  to  corroborate  what  he  has 
said,  by  personal  observation  of  two  cases.  He  calls  attention  to  violent 
and  forcible  flexion  as  a  phenomenon  of  the  convulsions  occurring  in 
cerebellar  trouble.  The  head  is  forcibly  drawn  backwards,  a  certain 
amount  of  opisthotonus  is  conspicuous,  and  at  the  same  time  there  is  ex- 
treme flexion  of  the  upper  extremities,  so  that  the  fists  are  tightly  clenched, 
the  elbows  are  bent,  and  there  is  rigidity,  of  a  very  decided  character. 
This  condition  is  observed  most  perfectly  just  before  death.  The  tendon- 
reflex  has  been  found  by  Sepelli  to  be  present  in  diseases  of  this  organ. 

The  oculo-motor  symptoms  are  also  a  feature  of  cerebellar  aflections, 
and  chief  among  them  is  nystagmus,  the  eyeballs  being  rolled  either 
upwards  and  downwards,  or  from  side  to  side.  The  pupillary  changes 
following  an  irritative  lesion  of  this  organ  consists  as  a  rule  in  con- 
traction which  may  vary  in  extent,  and  it  is  not  uncommon  to  find  a 
want  of  response  to  light  stimulation.  Amblyopia  is  apt  to  occur  when 
the  anterior  and  lower  part  of  the  cerebellum  is  involved,  and  it  may  be 
either  double  or  single,  and  is  a  late  symptom  of  decided  significance;  in 
a  great  number  of  cases  optic  neuritis  is  present. 

The  general  convulsions  of  cerebellar  disease  are  somewhat  peculiar, 
from  the  fact  that  there  is  often  rolling  of  the  body  Avhich  is  associated 
with  some  fixed  deviation  of  the  eyeballs.  The  experiments  of  Majendie, 
Flourens,  Brown-S(iquard  and  Ferrier,  prove  that  these  rotatory  move- 
ments with  the  long  axis  of  the  body  are  constant  results  of  cerebellar 
irritation,  and  they  occur  in  the  direction  of  the  affected  or  irritated  side, 
a  fact  which  is  of  service  in  localization,  as  we  shall  see  hereafter. 

There  is  usually  a  sense  of  weariness  complained  of  by  the  patient, 
though  never  paralysis,  unless  other  parts  are  implicated  in  the  diseased 
process.  A  prominent  sensory  disturbance  is  the  sub-occipital  headache, 
which  is  distressing  and  painful,  and  quite  common.  There  may  ex- 
ceptionally be  hypersesthesia  of  the  scalp,  though  an  abnormal  modi- 
fication of  the  general  cutaneous  sensibility  is  rare.  ^  Luys,  in  100  cases 
of  cerebellar  disease,  did  not  find  any  affection  of  general  sensibility, 
at  least  anaesthesia  which  was  uncomplicated,  in  any  of  them.  He,  how- 
ever, called  attention  to  what  has  been  observed  by  Rendu  ^  and  others, 
viz. :  that  tactile  sensibility  is  slowly  affected  in  cases  of  cerebellar  he- 
morrhage. Affections  of  special  sensibility  are  common  enough,  and 
amaurosis  may  be  cited  as  a  symptom  of  frequent  occurrence.     It  is  ex- 

1  Arehiv.  G^n.  de  M6d,  1864,  p.  580. 

^  Des  Anesth^sies  Spontanees.     Paris,  1875,  p.  51. 


DISEASES    OF    THE    CEREBELLUM.  225 

ceptional  that  we  find  any  prolonged  disturbance  of  the  intellect,  as  we 
know  this  region  to  have  little  or  no  connection  with  the  higher  mental 
processes. 

CEREBELLAR   HEMORRHAGE. 

The  symptoms  of  this  form  of  disease  are  difficult  to  diagnose,  because 
of  the  liability  of  the  sanguineous  efi'usions  to  invade  other  parts  in  the 
neighborhood,  notably  the  pons  and  medulla.  Hemorrhage  limited  to 
this  region  rarely  produces  loss  of  consciousness,  but  leaves  a  train  of 
after-symptoms,  which  consist  of  vomiting  and  ocular  disturbances,  such 
as  loss  of  vision,  contracted  pupils,  together  with  clumsiness  of  speech,  and 
probably  the  uncertain  gait  which  has  been  before  spoken  of.  If  there  is 
paralysis,  it  will  be  slight  and  incomplete,  unless  the  outpouring  of  blood 
be  large,  and  then  important  adjacent  motor  regions  are  involved. 

Carion^  thus  speaks  of  cerebellar  hemorrhage: — "The  predominating 
symptom  of  cerebellar  hemorrhage  is  general  enfeeblement  of  the  muscu- 
lar system.  Hemiplegia  is  relatively  rare  ;  when  it  exists  if  is  sometimes 
crossed,  sometimes  direct.  Facial  paralysis  is  exceptional ;  it  involves 
the  orbicular  muscle  of  the  eyes,  and  occurs  on  the  side  of  the  lesion,  and 
it  has  for  its  cause  the  compression  of  the  seventh  pair  at  its  point  of 
emergence.  The  tongue  presents  a  certain  degree  of  asthenia,  shown  by 
a  weakness  in  its  movements,  without  deviation.  Strabismus,  like  the 
facial  paralysis,  is  not  observed  as  a  symptom  of  cerebellar  origin ;  it  may 
occur  from  compression  of  some  one  of  the  motor  nerves  of  the  eye.  The 
conjugated  deviation  of  the  eyes  has  been  observed ;  it  always  occurs 
towards  the  uninjured  side  as  for  other  parts  of  the  encephalic  isthmus. 
The  pupils  are  sometimes  dilated — more  frequently  contracted;  they 
sometimes  react  under  the  influence  of  light,  and  are  insensible.  General 
sensibility  is  unaltered  even  when  hemiplegia  exists ;  we  barely  observe 
a  slight  anaesthesia  in  a  few  rare  cases ;  hypersesthesia  is  still  less  frequent. 
Troubles  of  special  sensibility,  principally  of  sight,  have  been  observed, 
but  they  are  very  rare  exceptions.  The  intelligence  is  generally  pre- 
served in  all  its  integrity.  Vomiting  is  scarcely  ever  absent,  and  it  can 
rightly  be  deemed  one  of  the  more  characteristic  symptoms  of  cerebellar 
hemorrhage." 

Broadbent  reports  two  cases  of  cerebellar  hemorrhage,  which  are  re- 
ferred to  by  Wilks.  Both  cases  presented  premonitory  symptoms  of  pain, 
but  the  other  evidences  were  decidedly  negative,  and  might  easily  be  mis- 
taken for  those  of  other  diseases.  Both  patients  died  from  rupture  into 
the  ventricles. 

A  syphilitic  endoarteritis  may  result  in  complete  stenosis  of  a  cerebel- 
lar vessel,  so  that  symptoms  of  ischsemia  are  expressed,  and  become  very 
decided  if  the  closure  is  complete. 

ATROPHY   (sclerosis)    OF   THE   CEREBELLUM. 

Atrophy  of  the  cerebellum  is  very  often  met  with,  and  in  many  cases 

^  Abstract  in  Chicago  Journal  of  N.  Disease,  vol.  ii.  p.  62. 
15 


226        DISEASES   OF   THE   CEREBRUM   AND   CEREBELLUM. 

is  recognized  only  at  the  autopsy.  It  is  as  a  rule  a  condition  beginning 
early  in  life.  In  those  cases  I  have  seen,  the  atrophy  was  connected  with 
shrinkage  of  the  cerebral  mass.  On  the  same  side  there  was  generally 
some  form  of  mental  imperfection  or  atrophy  of  one  side  of  the  body. 
Uncomplicated  atrophy  of  one  lateral  half  of  the  cerebellum  I  believe 
to  be  extremely  rare.  So  far  as  we  are  able  to  judge  the  symptoms  are 
those  which  indicate  other  forms  of  cerebellar  disease,  and  it  is  difficult 
before  death  to  distinguish  the  condition  under  consideration  from  cere- 
bellar tumor  of  slow  growth.  There  are  the  disorderly  movements, 
chronic  spasms,  usually  some  fixation  of  the  head  from  rigid  contraction 
of  the  muscles  of  the  neck,  sometimes  a  series  of  movements  affecting  the 
hands,  and  which  by  Sepelli  have  been  described  most  fully  in  a  case  re- 
ported by  him.  In  some  respects  (hey  resembled  those  of  multiple  scle- 
rosis, there  being  a  certain  amount  of  irregular  jactitation  with  tremor 
and  a  spasmodic  expenditure  of  force.  In  many  cases  "atheotoid" 
movements  are  presented. 

TUMORS    OF   THE   CEREBELLUM. 

Tumors  of  the  cerebellum  may  resemble  in  every  respect  those  found 
in  other  parts  of  the  brain,  so  far  as  their  general  structure  and  topo- 
graphy is  concerned.  Headache  is  usually  a  severe  and  constant  symp- 
tom, and  is  referred  to  the  back  of  the  head,  while  convulsions  are  quite 
severe  as  a  rule,  and  become  more  and  more  violent  and  frequent  as  the 
bulk  of  the  growth  increases.  Ocular  troubles,  such  as  amaurosis,  strabis- 
mus and  pupillary  changes  symptomatize  the  presence  of  growths  in  this 
region,  and  it  is  common  to  find  decided  retinal  changes,  such  as  atrophy 
and  hemorrhage.  The  disorderly  movements,  which,  if  once  seen,  can 
scarcely  be  mistaken  a  second  time,  are  nearly  always  present,  and  are 
connected  sometimes  with  tremor  and  special  paralysis  of  the  cranial 
nerves.  Alteration  of  the  muscular  sense  and  the  faculty  of  localization 
and  sensory  perception  are  quite  common.  Dr.  Webber  ^  reports  an  in- 
teresting case  of  cerebellar  tumor  with  headache,  vertigo,  vomiting  and 
a  species  of  convulsive  attack  with  aura.  There  was  atrophy  of  both 
optic  nerves  and  some  unequal  anaesthesia  of  both  sides  of  the  body,  the 
left  leg  and  right  hand  being  aflTected.     The  patient  died  suddenly. 

"  Autopsy. — Brain  only  was  examined.  There  were  a  few  spots  of  in- 
creased opacity  of  the  pia  mater  over  vertex.  Convolutions  universally 
flattened.  The  ventricles  contained  a  large  amount  of  serum,  twelve  to 
fifteen  ounces,  much  of  which  was  lost  and  not  measured.  On  the  under 
surface  of  the  cerebellum  in  the  median  line,  between  that  organ  and  the 
medulla  oblongata,  extending  a  little  farther  to  the  left  than  to  the  right, 
was  a  tumor ;  this  involved  both  lobes  of  the  cerebellum  and  measured 
about  three  inches  transversely.  The  medulla  oblongata  was  much  com- 
pressed and  flattened.  The  tumor  contained  five  cysts  :  two  of  which 
were  very  large,  and  two  others  very  small ;  a  large  cyst  projected  ante- 
riorly from  above  the  cerebellum  below  the  corpora  quadrigemina.    Sev- 

^  Boston  Med.  and  Surg.  Journal,  April  8,  1880. 


DISEASES    OF    THE    CEREBELLUM.  227 

era!  of  the  nerves  arising  from  the  medulla  were  thinned,  and  less  white 
than  usual." 

In  this  case,  as  in  many  others,  the  symptoms  developed  slowly,  and 
the  headache  before  death  was  much  less  severe  than  the  beginning,  be- 
cause of  the  capacity  for  accommodation  to  pressure  upon  the  part  of 
the  cerebellum,  which,  as  we  know,  is  not  readily  affected  by  ordinary 
mechanical  injury.  So,  too,  it  would  seem  that  the  more  serious  mani- 
festations of  symptoms  depend  upon  invasion  of  other  territories.  In 
most  of  the  cases  of  cerebellar  disease  I  have  been  able  to  investigate, 
death  resulted  from  softening  or  injury  extending  to  the  floor  of  the 
fourth  ventricle,  or  from  the  bursting'of  some  vessel  submitted  to  danger- 
ous pressure,  so  that  the  ventricular  cavities  become  flooded.  In  this  con- 
nection may  be  mentioned  a  case  in  which  the  jjost  mortem  examination 
was  of  great  interest. 

G.  L.  C,  set.  26,  of  nervous  temperament ;  general  health  good  ;  pa- 
rents both  alive ;  no  nervous  tendency  ;  never  had  syphilis.  Four  years 
ago  the  patient  became  irritable  and  morose,  and  continued  so  till  January, 
1873.  He  then  devoted  himself  to  hard  study,  and  rarely  took  exercise 
or  amusement.  Two  months  afterwards  he  became  debilitated,  and  had 
attacks  of  vomiting,  which  occurred  in  the  morning,  and  were  relieved 
somewhat  by  the  upright  position.  In  the  following  April  a  loss  of 
steadiness  of  the  lower  limbs  was  noticed.  He  reeled,  and  a  sudden 
fright  would  cause  him  to  fall.  He  no  longer  went  alone  on  the  street ; 
when  he  did  so,  he  reeled,  staggered,  and  felt  conscious  that  he  was  the 
object  of  curiosity.  His  face  became  congested,^  and  his  nose  very  red, 
although  his  habits  were  good.  He  went  to  the  seashore,  but  never- 
theless grew  worse,  and  derived  no  benefit  from  the  change.  About  this 
time  diplopia  troubled  him,  and  he  tried  various  devices  to  correct  this 
visionary  difficulty,  such  as  shutting  one  eye  and  looking  across  his  nose 
with  the  other,  but  without  relief.  In  August,  violent  headache  developed 
itself,  and  vomiting  was  frequent.  He  could  not  look  up  or  throw  his 
head  back  without  dizziness  and  pain.  Cathartics  and  local  blisters  did 
no  pei'mauent  good,  nor  did  the  bromides. 

3Iay,  1875.  The  patient  presents  the  same  symptoms.  He  is  very 
much  troubled  by  headache,  which  is  paroxysmal.  He  staggers  wildly, 
and  his  vision  is  not  improved.  On  the  day  before  his  death  he  went  to 
see  some  friends,  and  on  his  return  complained  of  a  terebrating  pain  in 
the  back  of  his  head.  He  went  to  bed,  and  slept,  under  the  influence  of 
chloral  hydrate.  When  his  wife  awoke  in  the  morning,  she  fourd  him 
dead.  He  had  evidently  died  without  any  convulsions,  or  she  would  have 
been  aroused.  The  night  before  his  death  there  was  some  mania,  and  he 
shouted  words  of  the  different  languages  he  spoke — German,  French, 
Italian — in  a  confusing  jargon. 

At  no  time  was  there  impairment  of  speech  or  deglutition ;  there  were 
never  ptosis,  deafness,  loss  of  smell  or  taste.  Paralysis  was  never  observ- 
ed, nor  were  there  convulsions  of  any  kind. 

Autopsy  eight  (?)  hours  after  death.  The  scalp  was  cut  through,  and 
the  exposed  surfaces  were  almost  black  with  blood.  On  removing  the 
bone  the  meninges  were  found  hypersemic  to  a  marked  degree,  the  spaces 
were  engorged  beneath  the  arachnoid,  and  in  the  ventricles  was  a  large 


228  DISEASES   OF   THE   CEREBRUM   AND   CEREBELLUM. 

amount  of  yellowish  fluid,  the  former  being  puffed  out  by  the  serum 
under  the  surface.  Nothing  unusual  was  noticed  in  the  hemispheres 
beyond  the  hypera^mia  before  alluded  to,  and  careful  slicing  of  the  basal 
ganglia  revealed  nothing  of  importance.  The  texture  of  the  nervous 
substance  was  normal.  At  the  base  of  the  brain  a  very  different  state 
of  affairs  was  found  to  exist.  From  before  backwards  there  were  evi- 
dences of  acute  inflammatory  action,  the  left  side  more  particularly 
being  the  seat  of  softening.  The  right  crus  of  the  optic  commissure 
was  very  much  disorganized.  There  was  a  well-organized  membrane, 
very  pink  and  net-like,  which  extended  over  the  inferior  surface,  one 
band  binding  down  the  left  root  of  the  optic  commissure. 

Beneath  the  lining  membrane  of  the  fourth  ventricle,  at  a  point 
beneath  the  lower  and  anterior  part  of  the  cerebellum,  was  an  effusion, 
with  softening  of  this  organ.  This  membrane  was  bellied  out,  and  had 
evidently  produced  death  by  direct  pressure  upon  the  calamus  scrip- 
torius. 

At  a  point  corresponding  to  the  middle  of  the  lower  vermiform  pro- 
cess of  the  cerebellum  was  a  small  hard  tumor,  about  two  centimetres 
in  length,  one  and  a  half  in  breadth,  and  the  same  in  thickness,  which, 
when  cut,  disclosed  a  red  jelly-like  centre,  and  a  hard  fibrous  exterior, 
resembling,  somewhat,  a  syphilitic  growth.  The  line  of  demarcation 
between  the  healthy  tissue  and  the  circumference  of  the  tumor  was  very 
well  marked.  Beneath  the  microscope  Dr.  E.  G.  Janeway  and  I  found 
it  to  be  a  glioma  of  the  firmer  kind,  there  being  a  fibrous  structure  con- 
taining the  characteristic  cells. 

After  hardening  pieces  of  the  cerebellum  and  the  medulla  oblongata, 
I  examined  them  microscopically.  The  evidences  of  disorganization  of 
the  nervous  elements  at  the  nuclei  of  the  vagus  were  apparent.  The 
nerve-cells  were  deprived  of  their  processes,  and  the  nerve-tubes  were 
broken.  The  sections  of  the  cerebellum  were  made  contiguous  to  the 
tumor,  and  here  I  found  considerable  thickening  of  the  neuroglia  and 
disappearance  of  nerve-tissue,  while  the  vessels  were  very  much  increased 
in  size. 


Strange  as  it  may  seem,  it  would  appear  as  if  the  progression  so  far  as  cure 
is  concerned  is  not  hopelessly  bad  as  the  nature  of  the  lesion  would  lead 
us  to  suppose.  This  is  especially  true  in  syphilitic  tumor,  and  I  have  kept 
the  notes  of  several  cases  in  which  cerebellar  tumor  was  diagnosed  and 
cures  were  effected  in  a  remarkably  short  space  of  time.  In  one  patient 
the  symptoms  had  existed  for  ten  years,  but  after  the  diagnosis  of  syphilis 
had  been  made,  and  mercurials  had  been  administered,  a  rapid  subsid- 
ence followed,  and  the  patient  was  almost  entirely  cured  within  a  year. 

As  a  rule,  the  symptoms  of  cerebellar  tumor  of  syphilitic  origin  are 
complicated  by  those  of  meningitis,  as  tumors  of  this  character  start  from 
the  investing  membrane  and  grow  inwards. 

In  a  few  cases  of  cerebellar  tumor  I  have  witnessed  mental  symptoms, 
but  these  are  rare.  In  the  case  of  G.  C,  an  attack  of  maniacal  excite- 
ment preceded  death.  We,  not  unusually,  meet  with  cases,  however,  in 
which  there  are  hysterical  complications,  just  as  there  are  in  right-sided 
organic  disease    of    the  cerebrum. 


DISEASES   OF   THE   CEREBELLUM.  229 

Aneurismal  dilatation  of  the  arteries  supplying  the  cerebellum  are 
occasionally  met  with,  and  such  a  case  is  related  by  Bristowe.^ 

J.  B.,  a  lighterman,  was  admitted  on  the  26th  of  October,  1858,  for  an 
attack  of  acute  rheumatism  (gout?).  No  distinct  account  of  the  previous 
duration  of  his  illness  was  obtained.  Five  days  after  admission  he  com- 
plained of  severe  epigastric  pain,  and  had  some  vomiting.  Shortly  after- 
wards he  became  comatose,  and  continued  so  until  his  death,  which  took 
place  on  the  2d  of  November. 

Fig.  34  a. 


Cerebellar  Aneurism.    (Bristowe). 

Post-mortem  Examination. — There  was  a  considerable  amount  of  serum 
both  on  the  surface  and  in  the  ventricles  of  the  brain  ;  and  much  athero- 
matous and  earthy  deposit  in  the  arteries  at  the  base,  and  their  branches. 
In  the  right  corpus  striatum  was  a  small  apoplectic  cyst,  but  in  other 
respects  the  brain-substance  appeared  healthy.  In  the  substance  of  the 
right  hemisphere  of  the  cerebellum  was  accidentally  discovered  an  aneu- 
rism about  twice  as  large  as  a  grain  of  wheat ;  it  was  irregularly  fusiform, 
its  parietes  were  thickened  and  hardened  with  atheromatous  and  earthy 
deposit,  and  it  gave  off  several  partly  ossified  branches,  each  about  half  a 
line  in  diameter.  Its  anterior  extremity  was  continuous  with  a  thin 
walled  healthy  vessel,  having  between  one-third  and  one-half  the  calibre 
of  the  aneurism  itself,  and  found  to  be  a  branch  of  the  right  superior  ce- 
rebellar artery.     Gouty  indications  were  found  at  different  points. 

SOFTENING  AND   ABSCESS   OF   THE   CEREBELLUM. 

Acute  and  chronic  softening  are  met  with  in  this  organ — and  as  a  result 
it  is  not  rare  to  find  abscess.  Cerebellar  abscesses  are  formed  in  this 
way,  or  depend  upon  the  breaking   down  of  an  old  clot,  as  was  the 

^  London  Pathological  Society's  Eeport,  vol.  x.,  p.  iv. 


230         DISEASES   OF  THE   CEREBRUM   AND   CEREBELLUM. 

case  in  an  example  reported  by  Dr.  Hughes,  of  St.  Louis,'  the  main 
symptoms  of  which  are  the  following  : — 

"  He  has  a  sense  of  fulness  in  the  head,  headaches  daily,  with  intensi- 
fied pain  and  throbbing  in  the  occipital  region,  especially  severe  in  the 
morniug  after  breakfast.  He  has  a  ravenous  appetite  ;  vomits  often,  es- 
pecially after  eating,  and  has  dizzy  spells. 


A,  Abscess.    B,  Cyst  containing  serum.     C,  Organized  apoplectic  clot. 

Before  the  headaches  came  on  he  would  sometimes  sleep  twenty-four 
hours  without  waking.  When  attempting  to  walk,  he  often  staggers  as 
though  he  were  drunk. 

He  sometimes  hesitates  for  words  to  express  his  ideas,  but  not  enough 
to  be  called  aphasic. 

Three  weeks  before  coming  under  my  treatment,  he  was  much  out  of 
his  head.  He  became  wild  and  delirious,  and  engaged  in  an  imaginary 
fight  with  his  wife  and  boy,  taking  down  his  gun  from  over  the  door  to 
shoot  them,  saying  he  must  defend  himself.  He  had  but  a  confused  re- 
membrance of  the  fact  afterwards.  He  complains  of  a  sound  as  of  hiss- 
ing steam  in  his  ears. 

His  sexual  appetite  was  neither  absent  nor  inordinate,  so  far  as  we 
could  discover.  His  mind  was  clear  up  to  the  hour  of  his  death,  and  a 
few  hours  before  that  event  he  walked,  though  somewhat  clumsily,  about 
his  room.  A  few  minutes  before  he  died  he  sat  up  in  bed,  clasping  his 
bands  to  his  head  and  crying  out  with  intense  pain.  He  became  coma- 
tose without  convulsive  or  other  premonitions,  and  fell  back  on  his  pillow 
and  in  a  few  moments  expired. 

On  removing  the  cerebellum,  pus  and  serum  escaped  through  a  small 
opening  in  the  membrane  not  caused  by  laceration -or  scalpel  puncture. 

The  abscess  occupies  the  lower  half  of  the  left  hemisphere  of  the 
cerebellum,  extending  forwards  and  upwards,  so  as  to  obliterate  all 
traces  of  the  corpus  dentatum,  and  backward  and  downward,  so  as  to 


^  Journal  of  Mental  and  Nervous  Disease,  October,  1877. 


DISEASES    OF    THE    CEREBELLUM.  231 

communicate  with  an  apoplectic  cell,  about  the  size  of  a  hazel-nut,  filled 
with  serum. 

This  cell  extended  from  the  surface  through  the  arbor  vitae  arrange- 
ment, and  opened  into  the  abscess. 

The  cavity  of  the  abscess  was  immediately  above  and  contiguous  to  the 
organized  apoplectic  cyst,  located  just  beneath  the  arachnoid  membrane, 
and  occupying  the  striated  structure  at  the  extreme  posterior  inferior 
part  of  the  left  cerebellar  hemisphere,  and  just  within  the  median  line. 

This  organized  blood-clot,  though  now  a  little  shrunken  from  long  im- 
mersion in  alcohol,  was  about  the  size  and  shape  of  a  butter-bean. 

The  apoplectic  products  did  not  invade  the  right  hemisphere.  The 
abscess  did  not  implicate  any  part  nearer  the  middle  of  the  tuber  annulare 
than  one  and  a  quarter  inches,  and  of  course  did  implicate  the  crus  cere- 
belli. 

The  cavity  of  the  abscess  was  large  enough  to  envelop  a  large-sized 
almond,  and  was  filled  with  pus. 

A  careful  examination  revealed  no  lesion  of  the  cerebrum. 

The  weight  of  the  brain,  including  the  pons  varolii,  medulla  oblongata 
and  membranes,  was  forty-eight  ounces  and  a  half.  The  weight  of  the 
cerebellum,  medulla  and  pons,  after  evacuating  the  abscess  and  cell  of  their 
pus  and  serum,  was  four  and  one  half  ounces. 

The  opposite  cerebellar  hemisphere  appeared  neither  congested  nor  in 
any  other  manner  diseased. 

There  do  not  seem  to  be  any  very  peculiar  or  distinctive  symptoms  of 
cerebellar  abscess.  In  many  cases,  in  fact  in  enough  to  give  the  symp- 
tom more  importance  than  it  receives,  there  is  deafness.  The  patient  is 
more  comfortable  in  the  upright  position,  and  there  seems  to  be  more  fre- 
quent vomiting  than  in  other  forms  of  cerebellar  diseases. 

The  coexistence  of  aural  disease  sometimes,  either  leads  us  to  ignore 
the  cerebellar  trouble,  or  decide  at  once  that  the  latter  is  a  result  of  the 
former,  which  is  not  always  warrantable.  The  diagnosis  is  sometimes 
made  by  the  ophthalmoscope,  and  I  may  refer  to  Hughlings  Jackson,^  who, 
in  alluding  to  the  importance  of  this  instrument,  insists  upon  the  point 
that  very  often  we  have  no  reason  to  suppose  that  there  exists  any  impair- 
ment of  the  visual  apparatus,  at  least  so  far  as  the  patient's  ability  to 
read  is  concerned. 

In  a  case  seen  by  him  the  symptoms  pointed  strongly  to  aural  dis- 
ease with  cerebellar  symptoms,  but  an  ophthalmoscopic  examination  re- 
vealed double  optic  neuritis,  though  there  was  no  cranial  nerve  paraly- 
sis. She  saw  perfectly,  though  her  retinse  were  the  seat  of  disease.  A 
post-mortem  examination  revealed  an  abscess  in  one-half  of  the  cerebel- 
lum of  great  size. 

Pathology  and  Morbid  Anatomy. — The  results  of  much  experi- 
mentation show  that  injury  or  disease  of  the  cerebellum  is  followed  not 
only  by  special  symptoms,  but  by  others  indicating  disturbance  of  the 
conjoined  function   of  the  cerebrum  and  cord,  and  that  as  this  organ 

^  Eemarks  upon  the  routine  use  of  the  ophthalmoscope  in  Cerebral  Disease,  p.  16. 


232  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

is  the  seat  of  the  so-called  "  muscular  sense,"  there  is  an  impairment 
or  abolition  of  this  function  as  well.  The  cerebellum  seems  to  play  a 
regulating  part,  if  such  an  expression  can  be  used,  for  there  are  a 
number  of  indirect  disturbances  in  the  functions  of  the  anterior  brain 
which  are  produced.  Bastian  refers  to  the  liability  of  the  cerebrum  to 
suffer  in  such  cases  by  reason  of  mechanical  vascular  interference- 
The  vense  galeni  which  empty  into  the  straight  sinus  are  subject  to  pres- 
sure when  the  middle  lobes  are  affected.  This  in  some  measure  accounts 
for  the  indirect  production  of  hemiplegia  in  a  number  of  cases  of  cere- 
bellar disease  while  in  other  forms  in  which  there  is  very  decided  de- 
struction of  the  cerebellum,  no  real  paralysis  occurs  but  simply  a  "  weak- 
ness." When  hemiplegia  occurs  it  is  sometimes  due  to  pressure  upon  the 
medulla,  and  is  irregular  in  its  production.  When  one  lateral  half  of 
the  cerebellum  is  the  seat  of  injury,  we  have  hemiplegia  upon  the  same 
side  of  the  lesion,  "  an  effect  really  induced  by  the  pressure  which  such 
lesion  occasions  upon  the  corresponding  side  of  the  medulla  oblongata." 

Irritation  of  the  cerebellum  by  means  of  electricity  has  been  found  by 
Hitzig^  to  result  in  a  peculiar  train  of  phenomena.  A  galvanic  current 
passed  through  the  head,  the  electrodes  being  placed  upon  either  mas- 
toid process,  produces  immediate  dizziness  and  a  disturbance  of  equili- 
brium, depending  upon  the  position  of  the  anode  and  cathode?  The 
passage  of  the  current  from  the  right  to  left,  the  anode  being  placed 
upon  the  right  mastoid  process,  causes  a  vertigo  in  which  external  ob- 
jects move  from  right  to  left,  and  according  to  Ferrier,  Avhen  the  subject 
closes  his  eyes  he  feels  as  if  he  were  being  twirled  from  right  to  left ;  a 
contrary  state  of  affairs  occurs  when  the  poles  are  reversed.  The  eye- 
balls are  directed  to  the  side  of  the  body  towards  which  objects  seem  to 
move. 

So  far  as  the  loss  of  equilibrium  is  concerned,  it  has  been  found  that 
the  most  active  expressions  of  disturbed  motility  follow  immediately  after 
the  injury  or  occurrence  of  the  lesion,  and  Ferrier  says  take  place  as  a 
result  of  the  "  sudden  derangement  of  the  self-adjusting  mechanism  on 
which  the  maintenance  of  the  equilibrium  mainly  depends." 

It  would  appear  from  the  records  of  ninety-three  cases  brought  together 
by  Andral,  and  a  dozen  or  more  cases  collected  by  Hughes,  that  a  very  con- 
siderable destruction  of  the  cerebellum  may  take  place  without  any  con- 
spicuous alteration  of  functions  so  far  as  motility  is  concerned ;  and  it 
would  also  appear  that  the  morbid  processes  characterized  by  hyper- 
trophy or  tumor  are  those  in  which  the  most  decided  phenomena  are  pre- 
sented, and  presumably  as  a  result  of  pressure  made  upon  other  parts. 
From  the  physiological  experiments  of  Ferrier  and  the  clinical  observa- 
tions of  Bastian  and  others,  we  may  roughly  approximate  as  follows  the 
localization  of  cerebral  disease : 

Injury  or  Disease  of  the  Middle  Lobes. — Pitching  forward  of  the  body. 

1  Quoted  by  Ferrier,  page  106. 
'^  Anode  :  positive.     Carthode ;  negative. 


DISEASES    OF    THE    CEREBELLUM.  233 

Affection  of  vision  due  to  irritation  of  optic  lobes.  If  the  upper  part  is 
affected :  nystagmus  to  the  right  horizontally — if  the  lower,  in  the  reverse 
direction.  Symptoms  indicative  of  cerebral  pressure  due  to  ventricular 
dropsy.     Increase  of  sexual  power  (?). 

Injury  or  Disease  of  Lateral  Lobes. — Rotatory  movements  towards  dis- 
eased side  (Schiff,  Ferrier,  Hitzig,  and  others).  In  cases  of  limited  dis- 
ease there  is  a  tendency  to  fall  towards  side  of  lesion,  rolling  of  eyes  up- 
wards, inwards,  and  towards  side  of  lesion.  Hemiplegia,  perhaps,  and 
when  found,  it  is  more  marked  in  the  leg  than  arm,  and  is  accompanied 
by  loss  of  sensation.  If  one  lobe  is  affected,  there  is  rarely  decided  loss 
of  power,  but  unsteadiness  and  weakness.  No  affection  of  speech  or 
deglutition. 

Injury  or  Disease  anterior  of  Anterior  Region. — Vertical  nystagmus, 
complicating  cerebral  disturbance. 

The  morbid  anatomy  of  the  cerebellum  presents  a  large  field  for  study ; 
and  Pierret,  Meynert,  Fischer,  and  Sepelli  have  recently  written  a  great 
deal  that  is  valuable.  Disease  of  this  organ  presents  ultimate  textural 
changes  that  differ  but  slightly  from  those  which  affect  other  parts  of  the 
brain.  The  commissural  fibres  are  often  found  to  be  the  seat  of  degene- 
rative changes  which  may  extend  to  the  cerebrum  and  the  cord,  and  it  is 
not  uncommon  to  see  atrophy  and  sclerosis  of  other  organs  in  the  vicinity 
in  connection  with  morbid  processes  in  the  cerebellum  itself.  In  some 
cases  the  pons  is  greatly  diminished  in  size,  while  it  is  to  be  observed  in 
others  that  the  cord  is  the  seat  of  secondary  degeneration,  as  a  result  of 
downward  extension  of  cerebellar  disease  ;  but  this  is  not  nearly  so  com- 
mon as  when  it  follows  cerebral  disease.  When  such  secondary  degene- 
ration exists,  it  may  be  explained  by  reference  to  the  anatomical  relation 
of  the  series  of  fibres  that  pass  either  across  the  median  cerebellar  pedun- 
cle or  through  the  medulla  to  enter  into  the  formation  of  the  anterior  and 
lateral  columns.  It  follows  in  certain  cases,  therefore,  that  secondary 
contractions  are  to  be  met  with;  and  in  a  patient  who  died  at  the 
Hospital  for  Nervous  Diseases,  there  was  besides  atrophy  of  the  cere- 
bellum and  cerebrum,  a  hemiplegia  with  secondary  contractures  and 
sclerosis  of  the  cerebellar  peduncles.  In  many  cases  the  cells  of  Purkinje 
will  be  found  to  be  altered,  having  undergone  granular  changes.  Soften- 
ing is  common,  and  this  may  be  readily  inferred  when  we  take  into 
account  the  rich  vascular  supply  of  this  organ. 

In  different  cases  of  abscess  of  the  cerebellum,  the  size  of  the  purulent 
collection  will  vary  greatly,  and  frequently  one-half  of  the  organ  is  found 
to  be  the  seat  of  a  cyst  filled  with  pus.  As  in  Hughes'  case,  these  cysts 
often  follow  old  hemorrhages.  ^Fox  presents  a  case  in  which  cerebellar 
abscess  existed  together  with  small  abscesses  of  the  cerebrum  and  lungs, 
and  another  in  which  a  large  abscess  in  the  central  part  of  the  left  hemi- 
sphere of  the  cerebellum  existed  with  distended  ventricles.  In  neither  of 
these  cases  was  there  any  apparent  cause. 

^  Pathological  Anatomy  of  Nervous  Centres. 


234       DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

The  vessels  liable  to  rupture  are  the  inferior  cerebellar  arteries,  the 
posterior  being  a  branch  of  the  vertebral,  and  the  anterior  a  branch  of  the 
basilar.  The  vessel  however  most  frequently  found  ruptured  is  the  su- 
perior cerebellar  artery,  usually  at  a  point  ■where  it  gives  off  a  branch  to 
supply  the  rhomboidal  nucleus.  The  arrangement  of  the  vessels  is  double 
and  there  is  free  anastomosis.  As  in  other  parts  of  the  brain,  the  hemorr- 
hages into  the  gray  substance  are  the  most  extensive,  and  this  is  especi- 
ally the  case  when  the  superior  cerebellar  artery  is  ruptured. 

Atrophy  of  the  cerebellum  is  usually  a  congenital  state,  although  it 
may  follow  low  inflammatory  processes,  or  be  due  to  osseous  deformities, 
as  in  the  case  cited  by  Otto.  Meningeal  thickening  may  induce  atrophy 
by  pressure. 

As  to  cerebellar  tumors,  we  find  that  glioma  prefer  this  seat,  though 
tubercule  is  by  no  means  rare. 

Diagnosis. — Cerebellar  disease  may  be  confounded  with  several  other 
forms  of  trouble  producing  disorders  of  motility.  Chief  among  these  are 
anomalous  varieties  of  locomotor  ataxia,  in  which  head  symptoms  are 
marked.  There  is  never,  as  I  have  stated,  any  disappearance  of  the  ten- 
don reflex,  though  atrophy  of  the  optic  nerves  may  be  present  in  both 
diseases.  I  have  repeatedly  met  with  cases  in  which  the  diagnosis,  so  far 
as  the  gait  was  concerned,  was  extremely  difficult.  In  cerebellar  diseases 
there  are  none  of  the  sensory  disturbances  so  marked.  The  neuralgic 
paina  in  the  lower  extremities  and  anaestheria  are  therefore  absent,  as 
are  the  crises  gastriques.  The  differential  diagnosis  between  cerebellar 
hemorrhage  and  that  in  the  cerebrum  is  not  so  difficult,  for  there  is  rarely 
any  loss  of  consciousness,  unless  the  hemorrhage  is  sufficient  to  flood 
other  parts.  The  symptoms  are  characterized  by  their  regularities  in 
their  grouping.  A  point  previously  stated  should  be  borne  in  mind,  and 
this  is,  that  the  paralysis — if  it  be  present — is  much  more  profound  in 
the  lower  extremities,  and  that  facial  paralysis  is  rare,  a  point  insisted 
upon  by  Bastian.  In  the  various  forms  of  cerebral  sclerosis  the  diagnosis 
is  quite  difficult;  in  fact,  the  cerebellum  is  rarely  the  seat  of  limited 
sclerosis,  as  in  cases  reported  by  Charcot  and  Bourneville  other  parts  of 
the  brain  were  affected  as  well. 

In  a  great  many  cases  disease  of  the  cerebellum  gives  rise  to  convul- 
sions, which  are  mistaken — and  not  without  reason — for  epilepsy.  They 
are  irregular,  however,  and  connected  with  such  marked  tonicity  that  they 
need  not  mislead.  Moreover,  they  often  occur  without  loss  of  conscious- 
ness, and  are  connected  with  vomiting  and  nystagmus,  and  are  always 
bizarre  and  rotatory. 

Prognosis. — The  most  faithful  and  intelligently  selected  treatment 
avails  but  little  in  cerebellar  disease,  except  in  certain  exceptions.  Syphili- 
tic disease,  in  this  region  I  have  found,  as  I  have  before  said,  to  be  much 
more  effectively  combated  than  when  it  involves  other  parts  of  the  brain. 
The  progress  of  cerebellar  disease  is  so  slow,  and,  as  a  rule,  is  so  rarely 
attended  by  serious  symptoms  as  to  be  less  alarming  to  the  patient  and 
physician  than  where  the  pathological  process  involves  some  other  region. 


DISEASES   OF   THE   CEREBELLUM.  235 

Treatment. — The  management  of  these  cases  is  very  much  like  that 
which  should  be  followed  in  general  cerebral  disease.  The  iodide  of 
potassium  in  large  doses,  arsenic  in  the  form  of  Fowler's  solution,  or  the 
bi-chloride  of  mercury  may  be  given  a  thorough  trial.  Counter-irritation 
by  means  of  a  seton,  or  frequent  cauterization  of  the  neck,  should  be  re- 
sorted to  as  well. 

In  a  case  of  syphilitic  origin  I  had  the  pleasure  of  witnessing  a  very 
rapid  disappearance  of  symptoms  when  the  patient  was  submitted  to  sys- 
tematic inunction  with  mercurial  ointment.  For  the  relief  of  the  intense 
headache,  the  ether  spray  to  the  occiput,  or  ether  applied  on  cloths  to  tha 
head,  as  recommended  by  Dr.  Hughes,  affords  great  relief. 


236  DISEASES   OF   THE   SPINAL   MENINGES. 


CHAPTEE  Yll. 

DISEASES  OF  THE  SPINAL  MENINGES. 
SPINAL  MENINGITIS. 

ACUTE   PACHYMENINGITIS. 

The  investing  membranes  of  the  spine  may  be  the  seat  of  chronic  or 
acute  inflammation,  together  or  singly,  though  there  is  generally  a  cer- 
tain amount  of  coexisting  myelitis,  and  consequently  the  meningitis  is  not 
an  uncomplicated  condition.  In  exceptional  cases,  however,  the  dura 
mater  may  be  affected,  and  the  resulting  affection  is  known  as  Spinal 
Pachymeningitis ;  or  the  pia  mater  and  arachnoid  in  other  cases  are  the 
seat  of  such  inflammation  ;  or  the  three  membranes  may  be  together  in- 
volved. 

INFLAMMATION  OF   THE  SPINAL   DURA   MATER,    OR   SPINAL 
PACHYMENINGITIS. 

Michaud  ^  has  given  the  name  external  jyachymeningitis  to  the  form 
which  results  from  pressure  made  by  diseased  vertebrae,  and  coexisting 
with  Pott's  disease,  while  other  varieties  have  been  described  as  internal 
hemorrhagic  pachymeningitis  (Meyer  ^  and  Schuberg'^)  and  cervical  hyper- 
trophic pachymeningitis  (Charcot '}.  The  form  described  by  Meyer  is 
almost  identical  with  that  which  involves  the  cerebral  dura  mater,  and  in 
which  there  is  thickening  and  encysted  clots.  As  the  name  indicates, 
the  form  described  by  Charcot  is  confined  chiefly  to  the  cervical  portion 
of  the  spinal  dura  mater. 

ACUTE   AND   CHRONIC   SPINAL   MENINGITIS. 

Symptoms. — This  disorder,  which  commonly  involves  all  three  mem- 
branes, is  generally  ushered  in  by  a  chill,  followed  by  elevation  of  tem- 
perature ;  a  hard,  full  pulse,  and  excruciating  pain.  This  pain  is  increased 
by  any  movement  the  patient  may  make.  He  tries  to  relieve  his  suffer- 
ing by  changing  his  position  and  by  keeping  quiet,  so  that  muscular  rigid- 

1  Sur  la  M6ningite,  etc.     These  de  Paris,  1871. 

^  De  Pachymeningitide,  elc.  Dissertatio  inaug.  psych.  Aug.  Mever.  Bonn?e, 
1861. 

*  Vich.  Archiv.,  t.  xvi.  p.  481. 

*  Lecons  sur  les  Fonctions  du  Sys.  Nerveux,  fas.  1,  part  2,  p.  243,  etc 


SPINAL    MENINGITIS.  237 

ity,  which  is  semi-voluntary,,  is  often  mistaken  for  a  tetanic  spasm.  Pain 
darting  along  the  spinal  nerves  adds  all  the  more  to  his  misery,  and  his 
legs  are  forcibly  drawn  up.  Hypersesthesia  of  the  surface  is  generally 
present,  and  reflex  excitability  is  nearly  always  exaggerated  in  the  earlier 
stages.  The  head  is  sometimes  drawn  backwards  by  contraction  of  the 
post-cervical  muscles,  and  the  appearance  is  presented  which  is  so  well 
marked  in  cerebro-spinal  meningitis.  Should  the  meningitis  be  general, 
or  extend  upwards,  the  intercostal  and  phrenic  nerves  are  finally  involved, 
and  asphyxia  and  death  result.  The  tendency  in  many  cases  is  towards 
chronicity,  and  very  often  there  are  secondary  affections  of  the  cord  from 
pressure.  The  bladder  and  rectum  frequently  suffer  to  such  a  degree  that 
involuntary  discharges  of  urine  and  feces  result,  but  the  former  some- 
times escapes  the  involvement.  Should  the  disease  become  chronic,  it 
exists  in  a  modified  form,  the  pain  being  less  severe,  and  the  contractions 
of  the  limbs  more  marked.  The  skin  is  cold  and  hypersesthetic,  and  re- 
flex excitability  is  present  to  an  extraordinary  degree,  the  slightest  prick 
of  a  pin  being  sufficient  to  cause  violent  retraction  of  the  limbs.  The 
muscular  power  is  greatly  reduced,  so  that  the  individual  may  be  unable 
to  take  any  exercise.  The  bladder  trouble  is  much  more  marked  than  in 
the  acute  variety,  and  the  patient  may  find  it  necessary  to  empty  his  blad- 
der every  few  minutes.  Obstinate  constipation,  distension  of  the  bowels 
by  wind,  and  gastric  disturbances,  are  accompaniments.  If  the  cord  is 
involved,  there  may  be  presented  symptoms  of  meningo-myelitis,  and  then 
paralysis  of  motion  and  sensation  becomes  marked,  and  the  muscles  under- 
go atrophic  changes. 

The  case  of  Mr.  J.  E.  is  instructive.  He  is  a  great  sportsman,  and  up 
to  four  or  five  years  ago  was  often  exposed  during  his  hunting  excur- 
sions. Four  years  ago,  during  one  of  these,  he  lay  for  several  hours  in 
a  "  battery,"  shooting  ducks.  The  weather  was  cold,  and  he  was  directly 
exposed  to  a  drizzling  rain.  On  the  same  night  he  was  seized  with  a 
chill,  which  lasted  for  nearly  an  hour,  and,  supposing  he  had  "caught 
cold,"  he  drank  altogether  nearly  a  tumblerful  of  whiskey.  During  the 
night  he  became  feverish,  complained  of  pain  in  the  back,  vomited,  and 
was  delirious  throughout  the  next  day  and  the  two  following.  His  pain 
was  excruciating,  and  the  slightest  jar  of  the  bed  caused  him  intense 
agony.  At  the  end  of  fourteen  days  he  was  moved  upon  a  mattress  to 
the  nearest  boat,  and  from  thence  to  the  railroad,  and  was  carried  to  his 
home  by  easy  stages.  For  a  month  or  to  after,  he  was  confined  to  his 
bed,  the  pain  gradually  becoming  less  intense,  and  his  strength  returned 
by  degrees.  He  presented  himself  to  me  with  the  history  I  have  just 
detailed.  For  the  past  year  he  has  had  spinal  pain,  which  he  refers  to 
the  last  dorsal  and  upper  lumbar  vertebrse.  It  is  constant  and  worse  at 
night,  and  increased  by  pressure.  There  is  gastrodynia,  and  pains  down 
the  back  of  the  thighs,  which  seem  to  increase  after  exercise.  He  com- 
plains of  loss  of  power  in  the  legs,  and  cannot  walk  more  than  a  block 
or  two  without  being  greatly  fatigued,  and  at  night  his  legs  are  jerked 
up  during  sleep.  For  the  past  year  he  has  had  great  distress  and  dis- 
comfort, as  he  cannot  hold  his  water,  and  is  obliged  to  empty  the  blad- 
der every  few  minutes.     His  bowels  are  so  constipated  that  he  finds  it 


238 


DISEASES    OF    THE    SPINAL    MENINGES. 


necessary  to  use  an  injection  every  night.  Examination  revealed  pain 
upon  pressure  over  the  two  lower  dorsal  vertebrae,  analgesia  and  anaes- 
thesia of  the  cutaneous  surface  of  the  posterior  region  of  thigh.  The 
glutei  muscles,  as  well  as  the  adductors  of  the  thigh,  were  much  reduced 
in  size,  and  did  not  contract  as  powerfully  as  did  those  in  the  neighbor- 
hood when  subjected  to  electrical  stimulus.  His  abdomen  was  tympanitic 
and  greatly  distended.  He  had  become  despondent  during  the  past 
year,  and  neglected  his  business.  In  addition  to  the  pain,  loss  of  power, 
and  the  other  symptoms  I  have  enumerated,  there  has  been  a  sense  of 
abdominal  constriction  at  the  level  of  the  painful  point.  Damp  weather 
aggravates  the  pain,  and  he  has  periods  of  improvement,  when  he  goes 
to  Florida  or  some  other  warm  region. 

SPINAL   PACHYMENINGITIS. 

Symptoms. — The  forms  of  pachymeningitis  cannot  be  during  life 
separated  as  a  rule.  There  may  be  no  acute  stage  whatever,  but  a 
gradual  appearance  of  symptoms  indicative  of  slowly  developed  pressure 
upon  the  cord.     The  form  described  by  Charcot^  runs  its  course  in  five 


Deformity  of  Hand  in  Cervical  Pachymeningitis  (Cliarcot). 

or  six  years,  and  the  cervical  enlargement  of  the  cord  is  the  part  which 
suffers  the  most.  Pressure  is  made  upon  the  cord  itself,  and  upon  the 
nerve-trunks,  so  that  partial  or  total  loss  of  function  ensues.  There  is  a 
painful  stage,  the  premiere  periode  of  Charcot,  which  lasts  several  months, 
the  pain  being  intense  at  the  back  of  the  neck  and  in  the  upper  extremi- 
ties. With  these  pains  there  is  rigidity  of  the  upper  extremities,  and  the 
head  is  drawn  backwards  and  downwards  in  the  manner  I  have  before 
described.  There  are  in  addition  formication  and  disagreeable  sensations 
in  the  upper  extremities,  twitching,  and  some  paresis,  which  ultimately 


1  Op.  cit. 


SPIXAL    MENINGITIS.  239 

increases,  so  that  the  individual  retains  but  little  power.  Charcot  has 
obfe^erved  eruptions  of  bullas  and  pemphigus  as  evidences  of  lowered  vital- 
ity. After  this  period  there  is  atrophy  of  the  paralyzed  muscles,  partic- 
ularly those  innervated  by  the  ulnar  and  median  nerves,  while  those 
■which  are  supplied  by  the  radial  escape  the  atrophic  change,  and  deform- 
ity often  results  which  somewhat  resembles  the  main  en  griffe  of  pro- 
gressive muscular  atrophy,  diminution  and  loss  of  electrical  excitability. 
The  preceding  cut  from  Charcot  represents  the  appearance  of  the  hand 
in  this  condition. 

Contractions  of  the  paralyzed  muscles  ultimately  follow  the  paresis, 
and  the  skin  becomes  decidedly  ansesthetic,  so  much  so  that  a  pin  may  be 
inserted  without  any  expression  of  suffering  from  the  patient.  It  is  very 
rare  for  the  lower  extremities  to  be  implicated,  and  the  medulla  seems  to 
escape  the  effects  of  the  disease,  consequently  troubles  of  deglutition  or 
respiration  are  rare.  The  hemorrhagic  or  internal  form  of  pachymenin- 
gitis runs  a  most  irregular  course,  but  the  complicating  spiual  affections 
are  apt  to  be  much  more  marked  than  in  the  last-mentioned  variety.  The 
indications  of  internal  pachymeningitis  are  throbbing  pain  in  the  back, 
sudden  paralysis,  and  the  other  symptoms  to  which  I  have  alluded.  The 
disease  is  connected  with  hemorrhages,  and  consequently  there  are  at  in- 
tervals accessions  of  fresh  symptoms. 

In  a  large  number  of  cases  the  symptoms  may  be  due,  in  the  first  place, 
to  pressure  from  diseased  or  fractured  vertebrae,  and  pronounced  pain  of  a 
somewhat  local  character  is  a  prominent  initial  expression  of  trouble,  and 
this  will  be  followed  by  other  symptoms,  at  first  comparatively  localized, 
but  eventually,  the  pain  will  extend,  and  descending  or  ascending  ex- 
pressions of  compression  of  the  cord  will  be  manifested. 

The  large  number  of  cases  which  were  known  as  ''  syjDhilitic  paraple- 
gia "  some  years  ago  include  many  examples  of  chronic  syphilitic  pachy- 
meningitis, which  were  then  recognized  as  the  result  only  of  myelitis. 
The  progress  of  the  disease  is  much  more  slow  than  in  other  forms,  and 
the  patient  lasts  a  very  long  time,  and  is  sometimes  quite  cured  by  appro- 
priate anti-syphilitic  remedies.  The  acute  zymotic  fevers  are  not  rarely 
followed  by  pachymeningitis,  the  following  case  being  an  interesting 
example  of  this  occasional  sequel  of  typhoid  fever  : — 

Two  years  ago  Capt.  S.  recovered  from  an  attack  of  typhoid,  and  with 
convalescence  he  gradually  lost  power  in  the  right  hand,  right  leg,  left 
leg,  and  left  hand,  in  the  order  I  have  named  them  (this  is  his  statement). 
Preceding  these  conditions  there  were  shooting  pains  running  down  the 
spine  and  around  the  body.  He  was  paraplegic  two  months  afterwards. 
During  this  time  reflex  movements  were  easily  provoked.  "  When  my 
feet  came  in  contact  with  the  foot  of  the  bed,  if  the  cold  wood  touched 
them  they  would  fly  up."  He  evidently  had  the  contractions  which 
are  so  clearly  symptomatic  of  meningitis,  and  there  was  some  constipa- 
tion, but  no  bladder  trouble  except  atony.  His  neck  ''  felt  stiff,"  and 
he  was  occasionally  dizzy.  The  loss  of  power  in  legs  has  gradually  re- 
turned. 


240  DISEASES    OF    THE    SPINAL    MENINGES. 

Present  condition. — The  patient  walks  fairly,  with  no  apparent  impedi- 
ments. The  skin  is  slightly  hypersesthetic  ;  no  atrophy  of  any  muscles  ; 
has  good  muscular  strength  ;  there  is  slight  tenderness  produced  by  pres- 
sure over  the  vertebra  between  the  scapulie  ;  muscular  tension  at  back  of 
neck,  and  some  pain  with  movement ;  slight  distension  of  abdomen  by 
flatus  (he  says  this  is  a  constant  symptom) ;  bladder  and  bowels  in  excel- 
lent condition ;  some  very  trivial  effort  required  to  urinate  ;  no  headache, 
but  dizziness  caused  by  looking  upwards ;  no  loss  of  power  in  hands  or 
arms ;  no  constricting  band  ;  patient  can  stand  with  eyes  closed.  Co- 
ordination of  delicate  muscular  acts  unimpaired;  there  are  no  twitchiugs 
at  night  left.  I  suggested  the  propriety  of  giving  iodide  of  potassium  in 
addition  to  ergot,  which  he  had  taken  before.  I  also  recommended  the 
actual  cautery. 

One  of  the  characteristic  symptoms  of  all  forms  of  spinal  meningitis 
is  the  rigidity  of  the  spine,  and  there  is  an  increased  excitement  of  the 
tendinous  reflexes  which  may  be  unilateral  or  bilateral.  In  the  contracted 
limbs  the  percussion  hammer  produces  a  very  energetic  series  of  motor 
phenomena.  The  contraction  of  the  muscles  are  usually  aggravated 
when  some  voluntary  effort  is  made  to  overcome  them,  but  the  fingers 
of  the  patient  may  be  often  passively  extended  when  his  attention  is  di- 
verted. 

Causes. — According  to  Grisolle,^  spinal  meningitis  is  much  more 
common  among  men  than  women,  and  three-quarters  of  the  patients  are 
men  ;  and  Calmiel  considers  it  to  be  of  much  more  frequent  orgin  before 
the  thirtieth  year  than  afterwards.  Cold  and  intemperance  favor  its  ap- 
pearance, but  in  the  great  majority  of  cases,  it  is  of  spontaneous  origin, 
and  has  occurred  in  epidemics,  at  least  so  say  the  earlier  French  writers.^ 
In  1837  an  epidemic  appeared  at  London,  Versailles,  Avignon,  Metz,  and 
Strasburg,  and  there  were  no  atmospheric  causes  nor  any  influences  dis- 
covered which  could  account  for  its  appearance.  It  is  probable,  however, 
that  the  form  of  meningitis  was  cerebro-spinal,  with  the  history  of  which 
we  are  now  familiar.  Alcoholic  over-indulgence,  syphilis,  and  injury,  or 
vertebral  disease,  will  account  for  the  afiection  in  some  cases.  Like 
locomotor  ataxia  it  very  often  occurs  among  seafaring  men  who  have 
fallen  overboard,  or  have  been  obliged  to  stay  aloft  in  damp,  cold  weather. 
Pott's  disease  has  generally  been  supposed  to  have  little  to  do  with  the 
etiology  of  the  disease,  but  my  own  experience  and  that  of  professional 
friends  who  have  had  much  to  do  with  this  class  of  cases,  convince  me  to 
the  contrary.  In  a  case  of  this  kind  where  I  was  enabled  to  make  an 
autopsy,  I  found  great  thickening  of  the  spinal .  dura,  with  fibrinous  de- 
posits beneath  that  membrane  and  the  bone,  as  well  as  some  involvement 
of  the  nervous  substance  proper,  which  consisted  in  atrophy.  Fractures 
of  the  spine,  sometimes  unrecognized,  are  attended  by  so  much  injury  of 
these  membranes  as  to  give  rise  to  symptoms  which  may  be  either  sup- 


1  Op.  cit.  vol.  i.  p.  436. 

*  See  articles  in  Meraoires  de  1' Academie  Nationale  de  Med.,  t.  x.,  Kevue  M^dicale, 
and  Gaz.  Medicale,  1842. 


SPINAL    MENINGITIS.  241 

posed  to  be  due  to  myelitis  or  simple  concussion,  but  which  are  undoubt- 
edly occasioned  by  an  unrecognized  fracture.  Such  a  case  has  been  re- 
ported by  Mr.  Hutchinson,  in  which  the  individual  jumped  from  a  height, 
alighting  on  his  feet. 

Morbid  Anatomy  and  Pathology. — The  simple  forms  of  spinal 
meningitis,  that  is  to  say  the  acute  forms,  present  all  the  appearance  of 
violent  inflammatory  action  which  we  witness  in  cerebral  meningitis  : 
injection  of  the  pia  mater,  serous  or  purulent  effusions,  together  with  in- 
filtration of  adjacent  cellular  tissues,  more  posteriorly  than  anteriorly, 
and  perhaps  some  evidence  of  myelitis,  but  ordinarily  the  cord  is  healthy 
if  the  disease  be  uncomplicated.  The  region  affected  is  more  apt  to  be 
at  the  upper  part  of  the  cord,  but  there  may  be  inflammation  of  the  me- 
ninges covering  the  dorsal  or  lumbar  portions  as  well.  It  may  be  circum- 
scribed, as  the  result  of  pressure  from  displaced  vertebrse,  or  fracture,  and 
this  limitation  is  more  characteristic  of  pachymeningitis.  The  different 
membranes  may  be  adherent  to  each  other,  and  connected  with  the  cellu- 
lar tissue  in  the  vertebral  canal.  New  growths  beneath  the  dura  mater 
are  not  common,  but  may  be  found  sometimes  between  this  membrane 
and  the  bones.  In  cervical  pachymeningitis  there  is  great  thickening, 
and  in  old  cases  the  nervous  matter  is  compressed  to  such  a  degree  that  it 
is  atrophied,  and  may  be  found  to  be  hardly  two-thirds  its  normal  size. 
A  lamellar  arrangement  of  the  dura  mater  exists,  which  is  like  that  seen 
within  the  cranium,  and  the  other  membranes  may  be  quite  undistinguish- 
able  from  the  dura  mater,  and  consequently  the  cord  will  be  found  en- 
circled by  an  almost  homogeneous,  tough,  and  thickened  envelope.  The 
cord,  when  the  thickened  membranes  are  removed,  often  presents  an  irre- 
gular contour,  evidence  of  sclerosis  being  common.  The  lateral  and, 
posterior  columns  seem  to  suffer  most.  In  the  hemorrhagic  form,  there 
may  be  discovered  encysted  blood-clots  which  resemble  those  found  in 
cranial  hemorrhagic  pachymeningitis.  The  nerve-trunks  within  the 
vertebral  canal  will  be  found  to  be  covered  by  the  same  dense  tissue,  and 
the  peripheral  portions  of  the  nerves  are  often  atrophied.  Syphilitic  in- 
flammatory changes,  alluded  to  by  Buzzard,"^  are  sometimes  present,  with 
gummatous  growths  in  the  nerves  proceeding  from  the  cord. 

The  following  case  illustrates  the  morbid  anatomy  of  meningo-myelitis 
of  a  quite  extensive  character : — 

Idiot ;  Chronic  Spinal  Meningitis ;  Lobular  Pneumonia ;  Circumscribed 
Acute  Interstitial  Nephritis;  Chronic  Cystitis. — D.  A.,  set.  26,  admitted 
June  22,  1877.  No  previous  history  of  the  patient  could  be  obtained, 
except  that  she  had  been  an  inmate  of  the  almshouse  for  three  years  pre- 
vious to  admission,  where  she  was  confined  to  bed  entirely.  On  admission 
patient  was  very  much  emaciated  ;  legs  and  thighs  flexed.  She  was  un- 
able to  tatk,  but  almost  continually  screeched,  especially  at  night.  Two 
days  before  her  death  she  had  a  slight  diarrhoea..  On  morning  of  June 
28  had  elevated  temperature,  rapid  pulse,  and  cough.     Chest  could  not 

1  Syphilitic  Nervous  Affections,  p.  70. 

16 


242  DISEASES    OF    THE    SPINAL    MENINGES. 

be  satisfactorily  examined,  as  she  would  not  keep  quiet.  Moist  rales 
were  heard  over  entire  chest.  Patient  became  worse  during  the  day,  and 
died  at  4  o'clock  A.  m.,  June  29,  1878. 

Atdopsy  tivelve  hours  after  death,  made  by  Dr.  Maxwell,  the  Curator. — 
Rigor  mortis  present ;  body  small,  and  very  much  emaciated  ;  thighs 
flexed  and  adducted,  and  the  legs  upon  the  thighs,  and  contracted. 
Feet  oedematous.  Bed-sore  over  sacrum  and  nates.  Fingers  and  thumbs 
are  flexed ;  the  cranium  small ;  round,  low  forehead ;  hair  dark  ;  com- 
plexion brunette ;  eyes  brown. 

Head. — Bones  :  calvarium  circular ;  antero-posterior  diameter  six  in- 
ches ;  deep  Pacchionian  depression  on  right  side.  Dura  mater  and  sinuses 
normal.  A  little  over  three  ounces  of  fluid  in  subarachnoid  space.  Pia 
mater  over  the  convexity  meshes  is  markedly  elevated  by  cedema,  and  is 
opaque  in  latter  situation  ;  it  is  also  abnormally  adherent  over  convexity, 
and  in  Sylvian  fissure.  Weight  of  brain  and  cerebellum  22  ozs.  Exter- 
nally shows  nothing  except  that  the  sulci  are  wide.  Lateral  ventricles 
are  moderately  dilated.  Ependymoe  appear  normal.  Cerebellum  weighed 
H  oz.  Brain-substance  of  cerebrum  and  cerebellum,  gross  appearances 
normal. 

Spinal  Cord. — Adhesion  in  cervical  region,  betweeen  dura  mater  and 
wall  of  spinal  canal,  so  firm  as  to  require  section  for  its  removal ;  also 
another  point  in  dorsal  region.  Adhesions  between  opposed  surfaces  of 
arachnoid  in  cervical  region  quite  firm  and  general  on  the  posterior  sur- 
face ;  on  anterior  surface  scattered  filaments.  On  posterior  surface  of 
dorsal  region  a  few  filamentous  adhesions.  Dura  mater  in  cervical  region 
is  appreciably  thickened,  especially  the  upper  two  inches.  Pia  mater  cor- 
responding with  these  adhesions  has  brownish  appearance,  and  is  thick- 
ened. Veins  of  cord  are  filled.  Nearly  all  dorsal  portion  of  the  cord  is 
soft  to  the  feel.  Throughout  cervical  region  the  posterior  and  right 
lateral  columns  are  to  the  feel  firm  and  normal ;  have  bluish-gray  color, 
with  yellowish  streaks.  The  dorsal  portion  of  the  whole  cord  markedly 
softened.  Lumbar  region  and  caudae  equina,  to  gross  appearances,  show 
nothing  marked.  Dura  mater  surrounding  vertebral  foramina  is  thick- 
ened and  adherent  to  sheaths  of  upper  four  or  five  inches  of  cervical 
nerves.  Posterior  long  fissure  of  cord  of  the  dorsal  region  obliterated  by 
firm  adhesions  of  pia  mater. 

Prognosis. — The  patient's  chances  are  sometimes  good,  even  in  the 
chronic  form.  Charcot^  has  cured  one  case  of  cervical  pachymeningitis, 
and  doubtless  others  have  been  equally  successful.  In  the  great  number 
of  cases,  however,  a  fatal  termination  is  the  rule.  In  the  acute  form  death 
may  occur  in  six  days,  but  Tourdes  and  Chauflard  have  observed  cases  in 
which  this  termination  did  not  take  place  till  the  fortieth  or  fiftieth  day. 
In  acute  purulent  meningitis  the  pus  may  make  its  way  out,  pointing  ex- 
ternally, or  forming  an  abscess  in  the  muscular  tissue  of  the  back.  Cham- 
pion has  seen  a  case  of  this  kind  in  which  the  purulent  contents  of  the 
vertebral  canal  found  passage  through  at  the  third  lumbar  vertebra,  and 
formed  an  abscess  in  the  spinal  muscles.  This,  however,  is  exceptional. 
When  the  disease  results  from  Pott's  disease,  or  some  other  vertebral 
affection,  it  is  perhaps  possible,  by  mechanical  treatment,  to  improve  or 

^  Op.  cit. 


SPINAL    MENINGITIS.  243 

cure  the  patient ;  and  syphilitic  forms,  of  course,  are  generally  amenable 
to  treatment.  Death  may  occur  from  exhaustion,  and  is  preceded  by  the 
formation  of  bed-sores,  and  evidences  of  a  typhoid  state. 

Diagnosis.— It  is  necessary  to  diagnose  spinal  meningitis  of  the  acute 
form  from  myelitis,'-  especially  as  these  are  the  only  two  acute  spinal  mala- 
dies beginning  with  fever.  The  pain  is  much  more  severe  in  meningitis, 
and  is  aggravated  by  movement.  The  contractures  and  cramps  are  cha- 
racteristic of  meningitis,  and  are  not  connected  with  uncomplicated  mye- 
litis. Hypersesthesia,  and  exaggerated  reflex  irritability,  and  the  lighter 
grade  of  the  paresis  (there  rarely  being  paraplegia,  and,  if  there  is,  it  is 
quite  late),  are  suggestive  indications  of  meningitis,  which  should  prevent 
any  mistake.  The  chronic  forms  are  of  slow  development,  and  all  the 
symptoms  increase  progressively  after  their  appearance,  the  paralysis 
being  gradual  and  connected  with  contractures  of  the  afiected  limbs.  The 
paralysis  may  not  be  bilateral,  as  is  usually  the  case  in  syphilitic  menin- 
gitis, and  there  is  rarely  any  extension  of  the  disease  to  a  higher  or  lower 
level.  In  meningitis  there  are  none  of  the  atrophic  tissue  changes  of  the 
myelitis,  but  the  chronic  form  may  so  closely  resemble  chronic  myelitis  as 
greatly  to  puzzle  the  diagnostician.  The  anaesthesia  that  belongs  to  mye- 
litis, however,  is  rarely  present  in  meningitis ;  and,  if  it  should  be,  is  a 
late  and  slight  symptom. 

^  Tetanus  may  possibly  be  mistaken  for  meningitis,  but  such  an  error  in 
diagnosis  should  be  rare,  the  spasms  of  the  former  being  much  more 
general ;  and,  besides,  the  temperature  variations  are  entirely  different,  as 
the  thermometric  rise  in  tetanus  is  unattended  by  any  increase  in  the 
volume  of  the  pulse ;  while  in  acute  meningitis  the  temperature  and  pulse 
are  those  of  an  inflammatory  disease. 

Treatment.— The  acute  disease  must  be  met  with  energetic  treat- 
ment. Local  abstraction  of  blood  by  leeches  or  wet  cups  is  the  first  indi- 
cation. Kollet'  has  used  the  cautery  even  in  the  last  stages,  applying  it 
from  the  nucha  to  the  sacrum,  and  with  good  effect.  Chauffard'  has 
given  opium  in  large  doses  in  the  early  stages.  I  prefer,  however,  sup- 
positories of  opium  or  belladonna,  which  seem  always  to  relieve  the  pain, 
and  are  attended  by  the  additional  advantage  of  not  deranging  the 
stomach.  Blisters  applied  on  either  side  of  the  vertebral  column,  iodide 
of  potassium,  and  mercurials  (the  former  in  large  doses,  even  to  the 
amount  of  a  drachm  thrice  daily,  beginning,  however,  with  a  minimum 
dose),  are  excellent  remedies.  In  chronic  meningitis  I  have  repeatedly 
witnessed  the  beneficial  effects  of  ergot,  and  the  notes  of  the  case  I  present 
will  enable  the  reader  to  appreciate  its  immediate  and  powerful  action  in 
a  very  obstinate  example. 

B.  W.,  female,  aged  24  years,  single,  domestic;  admitted  to  hospital 
July,  1875. 


1  By  the  use  of  this  term  I  mean  not  only  general  myelitis,  but  those  localized 
forms  known  as  adult  and  infantile  spinal  paralysis. 

^  Memoires  de  I'Acad.  Nat.  de  Med.,  xx.  3  Eev.  Med.,  1842. 


244  DISEASES    OF    THE    SPINAL    MENINGES. 

July  6.  The  accession  of  her  trouble  began  about  eight  months  ago, 
when  severe  pain  in  the  lumbar  region  made  its  appearance.  This  was 
ver)'^  intense,  and  seemed  aggravated  by  the  supine  position.  About  ten 
days  after  this  appeared,  the  abdomen  became  tender,  and  there  were 
darting  pains  which  extended  about  the  body,  radiating  from  the  spine; 
this  abdominal  tenderness  continued  for  two  weeks,  and  then  disappeared. 
She  was  able,  at  the  end  of  a  month,  to  "  go  up  stairs,  and  to  move  about 
the  house."  A  few  weeks  afterwards  she  noticed  a  loss  of  power  in  the 
right  leg  and  thigh,  and  next  in  the  left ;  and,  a  month  later,  she  found 
it  impossible  to  get  out  of  bed  in  the  morning.  She  said  that  her  legs 
were  hypersesthetic,  and  spoke  of  feelings  of  "  pins  and  needles  "  in  the 
soles  of  both  feet.  She  says  that  she  thought  her  trouble  arose  from  a 
cold  that  she  had  caught  when  working  in  a  damp  place.  All  this  time  her 
pain  was  quite  intense,  and  there  has  been  no  improvement.  She  has 
great  difficulty  in  micturition,  and  is  constipated. 

I^th.  Painted  iodine  on  either  side  of  the  spine,  and  gave  her  gr.  v. 
potass,  iodid.  t.  i.  d. 

Aiig.  17.  Her  abdomen  has  been  distended  by  gas  for  the  last  two 
weeks.     Pancreatine  5ss  t.  i.  d.,  and  low  diet. 

24^/i.  This  treatment  has  not  diminished  the  size  of  abdomen.  Ordered 
milk,  rice,  and  beef-tea. 

ZQih.  Lumbar  pain  very  severe.  She  can  hardly  move  at  all,  and  is 
obliged  to  use  crutches.  Injections  of  tr.  assafoetida.  Charcoal  and 
water  fail  to  relieve  the  flatus.  The  abdominal  distension  is  quite  dis- 
tressing. 

31s^.  To-day^  another  injection  of  the  same  kind  did  no  good.  Insom- 
nia and  great  suffering,  as  the  lumbar  pain  is  severe  ;  prefers  her  bed,  and 
lies  on  the  left  side.  Chloral  hydrate ;  potass,  iodide.  Increased  convul- 
sive movements  of  legs. 

Oct.  9.  At  times  she  has  localized  pain  over  insteps  of  both  feet,  and 
pain  on  outer  aspect  of  right  knee.  For  the  last  five  days  slight  numb- 
ness as  far  up  as  her  knees.  Legs  have  "jerked  "  less  for  the  last  fort- 
night ;  can  move  well  in  bed  ;  very  slight  power  to  move  right  knee ; 
frequent  desire  to  urinate  ;  tympanites ;  some  colic,  pain  less  in  lumbar 
region.  Pulse  126,  small  and  irritable;  temperature  101io°-  Blisters 
every  other  night  on  either  side  of  the  spinous  processes. 

24i/i.  Abdominal  pain  lessened  ;  can  move  legs  more  freely ;  numbness 
less. 

Jan.  20,  1876.  Acidi  nitromuriat  dil.  has  relieved  constipation,  which 
has  been  a  constant  symptom. 

Feb.  7.  53s.  fl.  ext.  ergot  t.  i.  d. 

19^/t.  Ergot  has  had  wonderful  effect.  Patient  left  her  bed  yesterday, 
and  walked  to  the  front  door  of  hospital  (about  50  feet)  and  back  with- 
out fatigue.  She  steadied  herself  by  taking  hold  of  the  bedsteads.  Has 
discarded  her  crutches. 

25th.  Walks  well. 

March  15.  Goes  out  of  hospital. 

April  1.  Discharged  recovered.  This  patient  was  seen  six  months 
afterwards,  and  she  had  had  no  relapse. 

Ergot  has  acted  beneficially  in  other  cases  whicli  I  have  treated,  and  I 
am  of  the  opinion  that  it  is  more  valuable  than  any  other  remedy  in  both 
the  acute  and  chronic  varieties  of  spinal  meningitis.     The  actual  cautery 


SPINAL    TUMORS.  245 

applied  every  other  day  should  be  faithfully  used,  and  in  addition  we  may 
employ  setons  at  the  nucha  or  lower  down.  Cod-liver  oil  and  generous 
diet  are  to  be  prescribed,  and  every  measure  is  to  be  adopted  that  will  in 
any  way  build  up  the  patient.  Should  we  find  vertebral  disease,  a  suita- 
ble brace,  or  the  plaster-jacket  should  be  provided.  The  advantages  of 
Sayre's  suspension  treatment  can  hardly  be  overrated,  and  I  have  repeat- 
edly seen  very  decided  improvement  follow  the  separation  in  this  way 
of  diseased  vertebrse,  and,  consequently,  removal  of  the  pressure  upon 
the  nervous  tissues. 

SPINAL  TUMORS. 

The  growth  of  tumors  in  the  spinal  canal  or  cord  is  of  far  less  frequent 
occurrence  than  in  the  cranial  cavity  and  brain,  but  when  tumors  choose 
this  locality  their  presence  is  to  be  much  more  easily  diagnosed. 

The  varieties  of  spinal  growths  are  just  as  numerous  as  those  found  in 
or  about  the  superior  part  of  the  cerebro-spinal  axis.  They  may  be  of 
any  of  the  forms  I  have  named  in  speaking  of  cerebral  tumors,  but  those 
usually  met  with  are  the  following : — 

Sypliilomata. 

Fibromata,  attached  to  the  meninges,  or  in  the  substance  of  the  cord. 

Tuberculous  (rarely). 

Myzomata. 

Sarcomata. 

Parasitic  groivths  are  seldom  found,  and  the  other  forms  which  have 
been  spoken  of  in  our  consideration  of  brain-tumors  are  equally 
uncommon.  Exostoses  give  rise  to  many  obscure,  but  none  the  less  inter- 
esting symptoms,  while  sarcomata  are  occasionally  to  be  found  attached 
to  the  inner  surface  of  the  dura  mater  or  other  meninges. 

Spinal  tumors  are  of  slow  growth,  and  of  course  the  appearance  of 
symptoms  is  consequently  gradual  and  insidious. 

Symptoms. — The  first  indications  are  expressions  of  irritation,  and 
as  a  result  there  will  be  localized  pain,  and  various  disturbances  of 
motility  dependent  upon  the  aberration  of  that  part  of  the  cord  which  is 
the  seat  of  the  tumor.  Our  knowledge  of  physiology  of  the  cord  will 
enable  us  to  appreciate  that  disturbances  in  various  parts  will  be  followed 
by  symptoms  of  pain,^  hyperkinesis,  akinesis,  or  muscular  contractures 
expressive  of  involvement  of  the  posterior,  anterior,  or  lateral  columns, 
but  there  is  usually  no  such  possible  localization,  as  the  growth  generally 
impinges  upon  large  tracts  and  works  wholesale  mischief.  Compression 
is  followed  by  still  more  pronounced  symptoms  than  those  attendant  upon 
simple  irritation.  And  there  may  be  complete  paralysis  and  atrophy, 
with  muscular  contractures  of  the  members  either  of  the  upper  or  lower 
extremities.  Should  the  tumor  be  situated  high  up  in  the  cord,  the  mus- 
cles at  the  back  of  the  neck  may  be  the  seat  of  contractures,  and  those 
of  the  face  and  neck  may  even  sufier ;  if  the  tumor  be  seated  lower  down, 

^  Keynolds  considers  that  pain  in  the  back  is  more  intense  with  carcinoma  than 
with  tubercular  or  other  growths. 


246 


DISEASES    OF     THE    SPINAL    MENINGES. 


the  bladder  and  rectum  may  also  become  involved,  as  in  some  other  forms 
of  spinal  disease. 

Among  the  early  symptoms  may  be  mentioned  the  constricting  band 
which  is  connected  with  neuralgic  pains  that  shoot  down  the  legs.  These 
indicate  irritation  of  the  posterior  columns  and  nerve-roots.  There  is  also 
a  certain  amount  of  painful  rigidity  of  the  spinal  column.  Should  the 
anterior  column  and  nerve-roots  be  subjected  to  the  irritating  presence  of 
a  tumor,  the  consequence  of  such  trouble  will  be  convulsive  local  spasms 
and  increased  reflex  excitability.  Vomiting,  dizziness,  and  pupillary  dila- 
tation are  mentioned  by  Jaccoud  as  evidences  of  tumor  situated  in  the 
cervical  region,  while  nystagmus  and  strabismus  are  also  occasional  ex- 
pressions of  a  growth  so  located. 

The  paralysis  which  follows  increased  pressure  is  not  always  equal,  one 
limb  being  more  feeble  than  another  ;  or  there  may  be  hyperkinesis  on 
one  side,  and  paresis  on  the  other. 

Unilateral  irregular  troubles,  both  of  motility  and  sensibility,  are  the 
rule.  There  may  be  limited  and  well  defined  anaesthesia  and  analgesia  will 
be  found  on  the  side  opposite  the  lesion,  while  the  paralysis  may  be  the 

Fig.  36. 
MS        S  M 


striking  symptom  on  the  side  of  the  tumor.  This  may  be  explained  by  the 
diagram  of  Radcliffe,  which  I  have  slightly  modified.  Supposing  that  Fig. 
36  represents  a  segment  of  gray  matter,  we  will  consider  that  S  S'  repre- 
sent sensory  fibres  of  a  nerve-root,  and  M  M  motor  fibres.  The  sensory 
fibres  decussate,  S  going  to  one  side  of  the  body  while  S'  goes  to  the  other. 
M  and  M'  both  leave  the  cord  on  opposite  sides.  A  tumor,  pressing  upon 
either  lateral  half  of  the  cord,  such  as  "  I,"  may  simply  paralyze  motion  on 


SPINAL    TUMORS.  247 

the  same  side,  while  sensation  remains  unaffected,  and  both  sensation  and 
motion  are  intact  on  the  other.  If  deeper  pressure  is  made,  supposing 
"II"  to  represent  the  tumor,  not  only  would  motion  be  paralyzed  on 
this  side,  but  sensation  on  the  other.  If  a  tumor  such  as  "  III "  should 
impinge  at  the  decussation  of  the  sensory  conductors,  we  might  expect 
total  abolition  of  sensation  on  both  sides,  while  there  would  be  no  paraly- 
sis of  motion.  A  tumor  such  as  "  IV"  would  paralyze  sensation  on  both 
sides,  and  motion  on  one.  When  we  find  that  there  is  crossed  spinal 
paralysis,  one  arm  perhaps  being  involved  with  the  leg  of  the  opposite 
side  the  lesion  undoubtedly  occurs  in  two  points  of  the  motor  spinal  track 
at  a  place  above  the  decussation  and  below. 

Reflex  excitability  is  ordinarily  increased  in  the  limbs  below  the  lesion, 
but  it  is  stated  that,  when  the  inferior  part  of  the  lumbar  region  or  the 
Cauda  equina  are  destroyed,  reflex  excitability  is  abolished  after  a  period 
of  six  days,  and  that  then  the  muscles  begin  to  atrophy.  Jaccoud  ^ 
says :  "  There  is  here  a  new  application  of  the  law  I  have  endeavored  to 
make  clear.  As  long  as  cerebral  influence  only  is  deficient  in  the  infe- 
rior members,  the  reflex  and  electric  motility  and  nutrition  of  muscles  are 
intact,  but  when  the  spinal  influence  is  in  default  these  properties  are 
abolished." 

A  case  which  may  be  detailed  because  of  its  interesting  morbid  appear- 
ances and  which  during  life  seemed  to  refute  this  assertion  is  the  follow- 
ing, but  after  death  an  additional  tumor  was  found  higher  up,  which 
might  have  suspended  cerebral  influence,  and  still  have  left  a  portion  of 
the  cord  capable  of  giving  rise  to  reflex  movements  when  irritated  ;  but 
in  some  respects  the  case  still  renders  what  Jaccoud  has  said  somewhat 
doubtful,  as  the  question  arises  whether  the  larger  tumor  did  not  ante- 
date the  smaller,  and  whether  the  original  paraplegia  did  not  take  place 
before  the  growth  of  the  smaller  tumor  destroyed  the  cord.  The  patient 
entered  the  Epileptic  and  Paralytic  Hospital  September  18,  1872,  and 
was  examined  by  Dr.  Janeway,  Dr.  Seguin,  Dr.  MasoU;  and  myself,  and 
the  very  thorough  autopsy  was  made  by  Dr.  Maxwell. 

P.  K.,  aged  30  years;  occupation,  painter;  habits,  intemperate.  Inva- 
sion of  the  disease,  five  years  ago.  Relations  to  other  diseases,  disease  of 
the  spine.  Seat  of  paralysis,  lower  extremities.  Control  of  sphincters, 
very  poor.  Voluntary  movements,  imperfect.  Sensibility,  good.  Speech, 
good.     Hearing,  good. 

Patient  denies  venereal  disease,  and  no  indications  of  it  are  found  on 
examination.  He  states  that  ten  yeai's  ago,  after  an  attack  of  smallpox, 
he  noticed  a  pain  in  the  lumbar  region,  slight  and  irregular  in  occur- 
rence. 

Accompanying  this  pain  he  has  had  frequent  and  uncontrollable  desire 
to  go  to  "  stool,"  and  to  make  water,  but  could  not  do  either  to  his  satis- 
faction. This  all  continued  for  about  five  years,  when  he  noticed  that  he 
was  gradually  losing  control  over  his  lower  extremities,  and  in  five  months 
was  completely  paralyzed. 

1  Op.  cit.,  p.  352. 


248  DISEASES    OP    THE    SPINAL    MENINGES. 

Says  the  lefc  lower  extremity  remained  unaffected  the  longest,  and  in  a 
short  time  this  also  became  as  weak  as  the  right.  Has  no  control  over 
bowels,  and  has  but  little  control  over  the  bladder.  Physical  examina- 
tion reveals  a  slight  degree  of  right  lateral  curvature,  and  a  marked 
prominence  in  lumbar  region,  and  tenderness  on  pressure  at  a  point  cor- 
responding to  fifth  lumbar  vertebra.  These  signs  seem  to  point  to  lum- 
bar abscess,  as  there  is  slight  fluctuation,  and  the  cachexia  of  patient  is 
decidedly  indicative. 

Both  lower  extremities  are  much  atrophied,  soft,  and  flabby.  Patient 
very  anaemic.     Prescribed  iron  and  quinine. 

October  9.  Patient  since  examined  by  Dr.  Seguin,  who  says  the  ab- 
scess is  over  a  point  corresponding  to  upper  third  of  sacrum,  instead  of 
last  lumbar  vertebra,  as  was  first  supposed. 

\Ath.  At  the  age  of  thirteen  was  struck  in  the  small  of  the  back  with 
a  stick.  No  phthisis.  At  beginning  of  trouble  he  had  severe  pains  in 
dor.sum  of  feet,  with  swelling  and  short  lancinating  pains.  Pains  in  back 
part  of  the  thighs,  in  loins,  and  about  the  sides  of  pelvis.  No  inconti- 
nence of  feces.  Curvature  began  about  a  year  later  than  the  commence- 
ment of  paralysis.  When  limbs  were  extended  they  were  agitated  by 
clonic  spasms,  and  increased  pain  in  feet.  As  paralysis  increased  pain 
diminished,  although  diminution  was  not  noticed  until  after  contracture. 
In  last  two  years  no  material  change  has  taken  place.  Pain  at  irregular 
intervals,  and  occasional  spasms  in  legs  at  night.  Has  had  from  the  first 
a  feeling  of  coldness,  but  never  any  numbness.  Voluntary  movements 
at  hip-joint  quite  free.  Knees  flexible  at  an  acute  angle.  Extension 
and  flexion  possible  in  both  knee-joints  to  such  an  extent  as  to  bring  legs 
at  right  angles  to  thighs.  No  sign  of  voluntary  movement  below  knee- 
joints.  Passive  movements  free  at  hip-joints  for  extension,  which  is  con- 
siderably restrained  at  knee-joints.  Flexion  free,  extension  beyond  right 
angle  hindered  by  tension  of  flexor  muscles  of  thigh.  ]\Iore  free  at 
ankle-joints  and  toes ;  the  thighs  are  somewhat  wasted,  but  not  truly 
atrophied.     Lefc  measures  '61  \  centimetres  ;  right,  3:^  centimetres. 

The  legs  show  extreme  atrophy,  most  marked  on  right  side.  Left  calf 
measures  23?  centimetres;  right,  21?  centimetres.  The  feet  are  not 
cedematous.  The  integument  over  lower  half  of  tibia  is  apparently  hyper- 
trophied,  feels  elastic,  does  not  pit  on  pressure ;  the  appearance  is  like  that 
of  oedema.     The  bones  do  not  seem  to  be  enlarged. 

When  he  urinates  he  appears  to  empty  the  bladder  at  once,  but  does 
it  with  difficulty. 

Sensibility  decidedly  lessened  below  knee;  slight  impairment  of  feel- 
ing on  posterior  aspect  of  thighs.  Sensibility  much  impaired  below 
knees.  Impressions  of  pain  are  perceived  less  acutely  than  normal  at 
top  of  right  foot ;  less  acutely  on  left  foot.  Pricking  not  felt  on  left  toes ; 
slightly  perceived  on  right  toes. 

Claims  to  perceive  pressure  of  hands  on  both  feet.  On  irritating  soles 
of  feet,  slight  iavolantarg  movements  are  caused  in  thigh  muscles-  Legs 
and  feet  markedly  cold.  On  left  foot  has  ingrowing  nail,  with  ulcerated 
external  matrix.  The  right  toe  was  seat  of  ingrowing  nail,  with  ulcera- 
tion, some  months  ago.  Lower  limbs  perspire  easily  when  warmed  in 
bed.  Very  feeble  response  to  faradic  current  on  thighs  ;  feeble  reaction 
manifested.  No  response  in  leg  muscles.  Lower  lumbar  region  presents 
a  rounded  tumor,  about  2}  inches  in  diameter,  projecting  about  an  inch, 
and  situated  wholly  over  sacrum.     The  last  two  lumbar  vertebrae  are 


SPINAL    TUMORS.  249 

unnaturally  prominent.  Moderate  pressure  produces  no  pain  in  tumor  ; 
several  large  veius  lie  over  tumor,  whicli  is  elastic  to  feel,  and  gives  an 
obscure  deep  fluctuation. 

Deep  pressure  in  left  iliac  region  produces  but  slight  pain.  The  finger 
reaches  a  tumor  deep  in  abdomen.  Examination  by  rectum  shows  a  re- 
laxed sphincter ;  the  finger  meets  with  an  apparently  large  promontory 
of  sacrum,  which  is  moderately  elastic  ;  some  flactuation.  There  is  quite 
surely  a  tumor  involving  the  anterior  surface  of  sacrum.  Pressure  of 
finger  upon  pelvic  tumor  does  not  aflTect  external  dorsal  swelling. 

Patient  remained  in  the  hospital  for  a  year  after  this,  and  finally  died 
of  exhaustion. 

Autopsy  thirty-one  hours  after  death.  Rigor  mortis  passing  ofi".  Ab- 
domen of  greenish  discoloration.  Lower  extremities  contracted.  Left 
foot  slightly  oedematous  ;  muscles  of  extensors  atrophied ;  commencing 
decomposition  in  superficial  veins  ;  large  bed-sores  over  sacrum. 

Brain. — P.  M.  decomposition  ;  P.  M.  imbibition  along  vessels. 

Stomach  and  Intestines  are  apparently  normal.  The  pelvic  cavity  was 
filled  by  a  moderately  firm,  elastic,  ovoid  tumor,  extending  upward  out  of 
the  pelvis  as  far  as  lower  border  of  third  lumbar  vertebra  ;  the  psoas  mus- 
cles flattened,  and  spread  out  over  its  upper  and  outer  border  on  either 
side.  Aorta  and  inferior  vena  cava  raised  and  flattened  by  the  upper  end 
of  the  tumor  ;  the  external  iliac  vessels  raised  from  their  normal  situation 
and  course  over  its  lateral  borders.  All  of  above-mentioned  vessels 
empty ;  the  ureters  are  over  the  upper  border  of  the  growth,  and  are 
tightly  stretched  and  flattened. 

Bladder  contracted  ;  fundus  raised  out  of  pelvic  cavity ;  muscular  tra- 
becular flattened  ;  mucous  membrane  pale- around  openings  of  graudular 
follicles. 

Prostate  gland  elongated,  flattened,  and  atrophied  from  pressure. 

Recturn  raised  and  pressed  against  posterior  left  lateral  wall  of  bladder. 
The  growth  had  its  origin  behind  peritoneum. 

The  tumor  has  destroyed  the  whole  sacrum,  except  a  small  piece  of  its 
lower  end,  and  a  few  small  thin  plates,  from  here  and  there,  on  the  sur- 
face of  its  posterior  attachment;  the  fourth  and  fifth  lumbar  vertebrae 
were  wanting,  except  portions  of  laminre  and  spinous  processes  ;  the  body 
of  third  has  in  its  lower  border  a  large  concave  cavity. 

The  tumor  was  also  attached  to  the  lateral  wall  of  tlie  pelvis ;  the 
articular  surfaces  of  the  ilia  eroded  ;  the  right  most  destroyed.  During 
its  removal  large  cavities  were  opened,  from  which  a  thin,  yellowish,  viscid 
fluid  escaped,  more  or  less  colored  with  blood.  After  removal,  the  tumor, 
with  bladder,  prostate,  and  portions  of  rectum,  weighed  five  pounds ; 
measured  in  long  diameter  twelve  inches,  transverse  six  to  seven  inches. 
In  laying  it  open  on  posterior  attached  surface,  the  tumor  is  composed  of 
large  trabecul^e  and  solid  portions  inclosing  areola,  which  contained  the 
fluid  above  mentioned. 

The  surface  of  the  trabeculse  was  covered  with  small  and  large  villi, 
projecting  into  the  cysts  ;  the  general  color  was  yellowish  or  yellowish- 
brown  ;  in  certain  portions  hemorrhagic.  These  hemorrhagic  patches  are 
softer  than  the  yellow  "  consistency,"  and  there  were  solid  portions,  where 
it  was  quite  firm.  Microscopic  examination  showed  the  histological  struc- 
ture of  the  tumor  to  be  a  mvxo-fibroma-cavernosum. 


250  SPINAL    HEMORRHAGE. 

Spinal  Cord. — A  small  secondary  tumor,  about  two  inches  above  its 
lower  end  on  left  side,  behind  origin  of  anterior  roots  of  spinal  nerves. 
This  tumor  is  about  three-quarters  of  an  inch  by  half  an  inch  wide,  ovoid, 
reddish,  and  shining,  gelatinous,  and  attached  to  the  "  pia  mater."  The 
Cauda  equina  has  been  destroyed,  except  a  short  portion  of  the  origin  of 
the  nerves  composing  it ;  the  whole  cord,  but  especially  the  anterior  half 
below  cervical  portion,  softened,  presenting  numerous  varicosities. 

The  secondary  symptoms  of  spinal  tumor  are  those  which  are  generally 
known  as  "  compression  symptoms."  All  the  phases  of  secondary  de- 
generation follow,  and  after  a  variable  time,  the  patient's  taking  oflf  may 
occur  from  myelitis  and  exhaustion. 

Causes. — The  existence  of  the  tubercular  or  syphilitic  cachexia,  the 
indications  of  former  or  coexisting  syphilitic  symptoms,  and  the  history  of 
the  patient,  may  throw  some  light  upon  the  spinal  condition  ;  but,  after 
all,  we  know  very  little  about  the  etiology  of  spinal  or  other  tumors. 
Spinal  growths  are  rarely  found,  except  in  adult  life. 

Morbid  Anatomy  and  Pathology. — Syphilitic  deposits  are 
found  in  the  spinal  substance  between  the  meninges  and  about  the  nerve- 
roots.  The  exudation  resembles  that  found  in  the  brain  and  other  organs. 
The  site  of  these  deposits  is  chiefly  about  the  circumference  of  the  cord, 
and  is  rarely  central.  Tubercular  deposits  may  affect  the  entire  coz'd  and 
its  covering,  but  have  been  met  with  in  the  majority  of  instances  in  the 
gray  matter.  Jaccoud  says  that  they  are  nearly  always  found  in  the 
gray  matter  of  the  lumbar  enlargement.  Tubercles  may  be  found  co- 
existing in  the  cord  and  brain.  Myxomata  are  found  in  the  cord  much 
more  often  than  in  the  brain,  and  are  attended  by  separation  of  the 
nerve-fibres  and  great  mechanical  destruction.  Cancerous  growths 
may  and  usually  do  spring  from  the  vertebrae,  and  are  of  a  fungoid 
character.  Secondary  degenerations  are  to  be  found  in  certain  cases,  as 
well  as  aneurisms,  organized  clots,  cysts,  and  other  evidences  of  previous 
disease. 

Diagnosis. — It  is  not  an  easy  matter  to  distinguish  the  symptoms 
which  attend  spinal  tumor  from  those  of  some  of  the  other  spinal  diseases. 
We  should  bear  in  mind,  however,  that  the  indications  are  slowly  ex- 
pressed ;  that  the  paralysis  is  irregular  ;  that  one  group  of  muscles  may 
be  affected  at  first,  and  then  others ;  that  the  degree  of  lost  power  is  not 
the  same  on  both  sides  of  the  body ;  and,  also,  that  perverted  sensation 
is  not  the  same  over  the  two  sides ;  that,  usually,  there  are  contractures 
of  the  limbs  which  need  not  be  preceded  by  atrophy ;  and,  finally,  that 
pain  is  a  symptom  which  is  very  constant.  A  diagnostic  point  alluded  to 
by  Leyden  is  that  certain  movements  increase  the  spinal  pain  as  the  tumor 
is  compressed. 

Prognosis. — I  have  never  witnessed  a  recovery  from  spinal  tumor 
unless  the  character  of  the  growth  was  syphilitic,  and  doubt  very  much 
whether  a  cure  has  ever  been  effected.  It  is  impossible  to  limit  the  dura- 
tion of  disease  which  depends  so  much  upon  the  character  of  the  morbid 


SPINAL    HEMORRHAGE.  251 

growth.  Patients  may  last  for  eight  or  ten  years ;  or,  on  the  other  hand, 
they  may  live  a  very  short  time,  should  the  tumor  be  cancerous.  Death 
usually  occurs  by  pneumonia,  ursemia,  or  some  debilitating  disease. 

Treatment. — If  syphilis  be  suspected,  we  are  to  give  very  large 
doses  of  the  iodide  of  potassium  ;  or,  we  may  administer  the  biniodide  of 
mercury  in  combination  with  this  salt.  In  other  states,  supportive  treat- 
ment or  counter-irritation  offers  a  feeble  hope  of  relief  Morphia  or 
muscarin  may  be  injected  hypodermically  for  the  relief  of  pain. 

SPINAL   HEMOEKHAGE. 

meningeal;  central. 

Synonyms. — Hsematorrhachis  ;  hsematemyelie  (Ollivier).  Spinal 
apoplexy. 

Under  this  head  we  may  consider  the  effusion  of  blood  into  the  spaces 
between  or  under  the  meninges  of  the  cord,  and  the  effusion  of  blood  into 
the  substance  of  the  cord  itself. 

Symptoms. — Very  often  the  first  intimation  of  the  rupture  is  a  sud- 
den loss  of  power,  and  consequent  inability  of  the  individual  to  stand.  It 
may,  on  the  other  hand,  be  of  gradual  development,  the  symptoms  ap- 
pearing in  groups,  one  after  the  other.  The  resulting  paralysis  is  gene- 
rally complete,  and  the  patient  loses  both  motor  power  and  sensibility,  as 
well  as  control  over  the  bladder  and  bowels,  accompanied  by  a  number  of 
slowly-developed  symptoms,  with  diminution  of  reflex  excitability,  al- 
though the  latter  may  be  exaggerated  in  some  cases  should  the  hemor- 
rhage be  small  and  between  the  meninges.  The  abolition  of  muscular 
power  may  vary  in  proportion  to  the  gravity  of  the  hemorrhage,  and  if 
it  be  small  the  patient  may  ultimately  recover,  and  eventually  present 
no  indications  of  his  loss  of  power.  I  have  never  seen  a  fatal  termina- 
tion before  the  end  of  several  days,  and  doubt  if  such  xjould  be  the  case 
unless  the  hemorrhage  should  occur  at  a  very  high  point,  involving  a 
number  of  the  intercostal  nerve-roots  ;  but  even  this  is  improbable.  Of 
course  much  depends  upon  the  site  of  the  ruptured  vessel.  If  the  upper 
part  of  the  cord  or  the  medulla  be  affected,  then  an  immediate  and  fatal 
termination  is  a  natural  result.  Meningeal  hemorrhage  is  characterized  by 
more  pronounced  symptoms  of  muscular  rigidity,  or  by  convulsions, 
which  may  be  of  a  tetanic  character.  If  the  hemorrhage  has  taken  place 
above  the  fourth  or  fifth  dorsal  vertebra,  it  is  common  to  find  obstinate 
priapism  and  intestinal  disturbances,  giving  rise  to  flatus,  these  resulting 
from  paralysis  of  the  splanchnics ;  if  it  be  extensive,  there  may  be  para- 
lysis of  motion  and  sensation  from  pressure  exerted  upon  the  cord,  and 
pain  and  spinal  tenderness  are  also  quite  marked  symptoms,  and  in  uncom- 
plicated cases  there  is  cutaneous  hypersesthesia.  There  is  commonly  no 
loss  of  consciousness  in  either  variety,  but  when  the  effusion  takes  place 
in  the  medulla  there  may  be  conditions  akin  to  epilepsy.     In  this  case. 


252  DISEASES    OF    THE    SPINAL    MENINGES. 

however,  effusion  would  be  very  small,  and  the  region  affected  would  be 
near  the  circumference. 

Causes. — Spinal  hemorrhage  is  usually  the  result  of  a  traumatism, 
but  may  proceed  from  various  debilitating  maladies  and  some  of  the 
zymotic  diseases,  smallpox  playing  occasionally  a  part  in  the  etiology.  Al- 
coholism, and  other  conditions  in  which  the  cord  is  congested,  may  pre- 
dispose ;  or  the  hemorrhage  may  result  from  the  rupture  of  an  aneurism 
in  the  vertebral  canal,  such  as  occurred  in  Laennec's  case.  It  very  rarely 
takes  place  as  a  secondary  accident  in  tetanus,  so  that  it  can  be  recognized 
before  death;  but  at  the  post-mortem  examination  such  pathological  evi- 
dences may  be  occasionally  observed.  Traumatisms  undoubtedly  most 
frequently  produce  this  condition ;  and  falls,  blows  upon  the  back,  or 
concussion  following  a  fall  upon  the  feet,  enter  into  the  etiology.  It 
rarely  occurs  after  middle  age,  and  men  are  more  often  the  victims  than 
the  other  sex.  It  occurs  in  the  course  of  myelitis,  but  again  it  may 
happen  without  any  trace  of  inflammatory  trouble  to  be  discovered  after 
death  ;  and,  in  some  instances,  there  is  no  history  of  injury.  Such  a  case 
undoubtedly  resulted  from  sudden  congestion  at  the  menstrual  period, 
and  is  reported  by  Goldammer ' : — 

"  The  patient,  a  girl  of  about  sixteen  years,  was  suddenly  attacked  with 
a  severe  pain  in  her  back  between  her  shoulders,  which  soon  passed  over 
to  her  right,  and  after  a  while  to  her  left  arm.  She  also  noticed  a  pain 
in  the  pit  of  her  stomach,  and  found  somewhat  later  that  she  could  not 
move  her  right  leg.  Having  been  sent  to  the  hospital,  the  examining 
physician  found  complete  paraplegia,  complete  anaesthesia  up  to  the  ma- 
millie,  and  paralysis  of  the  bladder,  while  the  reflex  action  of  the  lower 
extremities  was  still  intact ;  her  temperature  was  normal,  pulse  80  ;  did 
not  show  any  brain  symptoms,  but  complaiued  of  pain  in  both  arms.  A 
few  days  afterwards  the  abdominal  and  dorsal  muscles  proved  to  be  par- 
alyzed, and  percussion  of  the  spinous  processes  of  the  dorsal  vertebrae 
caused  her  pain.  The  pulse  was  96  ;  her  bowels  moved  only  when  dras- 
tics were  given  her.  A  slimy  discharge  from  her  vagina  was  noticed. 
The  case  was  considered  as  hemorrhage  into  the  spinal  cord  below  its  cer- 
vical enlargement.  The  treatment  consisted  in  local  depletion,  in  the 
methodical  use  of  the  ointment  of  mercury,  and  in  the  use  of  drastics. 
The  patient,  having  improved  in  general  very  little,  died  from  decubitus 
about  a  year  after  the  attack.  The  most  noteworthy  observations  made 
on  autopsy  are  the  following:  About  one  inch  below  the  cervical  enlarge- 
ment of  the  spinal  cord  there  seemed  to  be  a  compressui-e.  A  cross  sec- 
tion through  this  part  showed  that  its  original  diameter  was  reduced  very 
much,  and  that  the  right  lateral  column  and  the  adjacent  parts  of  the  an- 
terior and  posterior  columns,  as  well  as  the  gray  substance  between,  were 
occupied  by  a  rusty  brown  substance  of  callous  consistence.  The  micro- 
scopic examination  of  this  proved  that  it  was  forujed  of  connective  tissue 
inclosing  fatty  matter,  crystals  of  htematoidine  and  a  granulated  brownish 
pigment;  the  vessels  in  this  part  had  undergone  fatty  degeneration,  their 
walls  were  thickened,  and  contained  brown  pigment;  no  nervous  element'^ 
could  be  found  in  this  substance;  its  entire  length  was  about  one  tenth  of 

'  Virchow's  Archiv.,  Jan.,  1876,  and  abstract  in  Med.  News. 


SPINAL    HEMORRHAGE.  253 

an  inch.  The  adjacent  parts  of  the  medulla  were  not  degenerated  by  sof- 
tening ;  only  a  few  rusty  stripes  and  a  yellowish  color  were  noticed  on 
their  examination  ;  the  whole  remaining  cord  was  found  to  be  intact. 
As  no  symptom  speaks  for  myelitis  as  a  causal  element  in  this  disease,  it 
could  only  be  caused  by  an  effusion  of  blood  into  the  substance  of  the 
cord :  the  latter  probably  had  been  provoked  by  suppression  of  the 
menses,  for  the  heart  and  the  vessels,  especially  those  of  the  spinal  mar- 
row, were  intact,  and  no  injury  had  occurred  to  the  patient.  It  is  true 
that  she  stated  she  never  had  had  her  catamenia  nor  noticed  any  moli- 
mina,  in  spite  of  her  age  and  bodily  development.  There  were,  also,  no 
signs  of  menstruation  noticed  during  her  sickness.  But  there  was  revealed 
by  autopsy  the  presence  of  a  corpus  luteum  of  the  size  of  a  pea,  and  cer- 
tainly of  long  standing;  and  a  slimy  excretion  from  her  vagina  was 
observed  a  few  days  after  the  attack.  These  facts  favor  strongly  the 
above-mentioned  suggestion." 

A  cause  alluded  to  by  Erb  is  the  disturbance  of  the  balance  of  pressure 
within  and  without  the  cord.  As  a  cause  of  this  kind  may  be  mentioned 
the  sudden  spinal  congestion  that  takes  place  when  an  individual  goes 
into  a  caisson  or  other  place  where  compressed  air  is  used.  Dr.  A.  H. 
Smith,  some  years  ago,  alluded  to  a  form  of  disease  which  occurred 
among  the  men  at  work  in  the  caissons  of  the  Brooklyn  bridge. 

Morbid  Anatomy. — Central :  hemorrhage  takes  place  into  the  up- 
per part  of  the  cord  more  often  than  in  any  other  locality,  but  the  lumbar 
and  dorsal  segments  may  also  be  its  seat.  The  gray  matter  is  naturally 
more  frequently  the  seat  of  hemorrhage  than  the  white,  and  when  pre- 
ceded by  myelitis  or  injury  it  will  be  generally  more  extensive  than  in 
the  latter.  If  the  hemorrhage  be  profuse,  we  will  find  that  the  cord  is 
enlarged  at  the  point  where  the  escape  of  blood  has  taken  place,  and  that 
it  has  a  doughy  feel.  Hemorrhage  into  the  meninges  may  be  sometimes 
associated  with  an  intracranial  condition,  the  blood  escaping  from  a  cere- 
bral vessel,  flooding  the  ventricles,  and  passing  down  into  the  spinal  cav- 
ity. Various  meningeal  diseases  may  terminate  in  this  way,  as  well 
as  spinal  congestion  and  tetanus,  and  occasionally  spinal  tumors  and 
vertebral  disease  give  rise  to  such  an  efiusion  of  blood.  Old  cysts  have 
been  found  in  the  cord  in  some  cases,  but  their  existence  is  comparatively 
rare,  and  when  met  with  they  present  the  same  appearance  as  is  seen  in 
the  brain,  though  of  course  they  are  much  smaller.  In  meningeal  hemor- 
rhage, the  coverings  of  the  cord  are  red  and  sufi"used,  and  perhaps  opa- 
lescent and  thickened,  and  there  is  possibly  some  meningitis  with  sero- 
purulent  collection  ;  the  efi'used  blood  may  be  found  as  a  semi-organized 
clot,  and  presents,  according  to  the  time  of  existence,  changes  of  color  of 
varying  depth.  The  size  of  the  clot  may  vary  from  a  few  millimetres 
in  diameter  to  a  much  larger  size.  In  some  instances  the  pia  mater  is 
torn  so  that  there  is  an  escape  of  blood  into  other  parts.  Occasionally 
the  condition  which  favors  the  development  of  spinal  apoplexy  may  lead 
tQ  cerebral  accidents  of  the  same  character,  and  evidences  of  such  trou- 
ble may  be  found  to  coexist.  Evidences  of  secondary  myelitis  are  quite 
common  about  the  lesion. 


254  DISEASES    OF    THE    SPIXAL    MENINGES. 

Diagnosis. — The  symptoms  must  be  distinguished  from  paraplegia 
due  to  myelitis,  and  from  those  of  cerebral  hemorrhage,  which  may,  as 
Brown-Sequard  has  lately  shown,  be  produced.  In  the  former  there  are 
primary  symptoms  which  I  will  discuss  in  speaking  of  myelitis,  and  in 
the  latter  there  is  usually  some  affection  of  consciousness,  and  some  dis- 
turbance of  speech.  This  latter  variety  of  disease  (cerebral  paraplegia) 
is  so  anomalous,  however,  as  to  have  but  little  weight  as  a  condition  to  be 
excluded.  The  subsequent  effects  of  such  a  hemorrhage,  paralysis,  con- 
tractures, etc.,  may  be  confounded  with  several  chronic  conditions.  Among 
these  are  spinal  tumors,  adult  spinal  paralysis,  and  ataxia.  The  first 
is  connected  with  decided  hyperkinesis,  is  of  gradual  development,  and  is 
accompanied  by  slowly  appearing  symptoms,  Antero-spinal  paralysis  or 
adult  spinal  paralysis  is  ushered  in  by  fever  and  unattended  by  any  loss 
of  sensation  or  incontinence,  and  the  atrophy  is  rapid.  Locomotor  ataxia 
is  symptomatized  by  increased  electric  contractility,  by  no  paralysis,  by 
disturbance  of  co-ordination,  by  absent  knee-phenomenon  and  by  optic 
nerve  and  pupillary  changes. 

Prognosis. — If  the  hemorrhage  takes  place  in  the  meninges  or  in 
the  lower  part  of  cord,  the  prognosis  is  perhaps  better  than  if  its  seat  is 
in  the  cervical  or  dorsal  segments.  In  the  first  instance  the  patient  may 
live  some  time  or  ultimately  recover,  but  in  the  latter  the  probability  of 
sudden  or  early  death  is  almost  certain.  Grisolle*  says  "Spinal  hem- 
orrhage runs  a  rapid  course.  A  single  patient  has  survived  forty  days  ; 
the  majority,  however,  succumb  at  the  end  of  several  days,  by  suspension 
of  respiration.  Among  others  death  is  hastened  or  produced  by  the  de- 
velopment of  bedsores.  Nevertheless,  spinal  hemorrhage  is  not  necessa- 
rily a  fatal  condition."  He  refers  to  a  case  observed  by  Cruveilhier,  and 
states  that  this  is  the  only  cure  of  which  he  has  known.  Erichsen,-  how- 
ever, has  reported  recoveries  which  have  taken  place  in  cases  which  were 
of  traumatic  origin ;  so  the  prognosis  is  perhaps  not  so  bad,  after  all. 

Treatment. — The  early  treatment  of  spinal  hemorrhage  should  con- 
sist of  cold  applications  to  the  spine,  perfect  quiet,  and  rest.  Subse- 
quently ergot  and  belladonna  will  be  of  great  benefit.  The  former  maybe 
injected  hypodermically  in  the  form  of  its  extract,  rather  free  doses  being 
used  which  should  be  repeated  frequently.  Five  or  even  ten  grains  may 
be  used.  Iodide  of  potassium  in  full  doses  does  good  sometimes.  Blis- 
tering and  leeches  to  the  painful  point  in  the  back  are  next  in  order,  and 
later  on  the  actual  cautery  is  the  most  serviceable  external  agent. 

^  GrisoUe,  Path.  Interne,  vol.  i.  p.  659. 
^  On  Concussion  of  the  Spine,  etc. 


SPINAL    HYPEREMIA.  255 


CHAPTER   YIII. 

DISEASES  OF  THE  SPINAL  COED. 
SPINAL  HYPEREMIA. 

(a)  spinal  congestion;    (b)  subacute  spinal  hyperemia. 

Two  varieties  of  spinal  hypersemia  exist :  one  of  sudden  origin,  and  of 
a  sthenic  character,  which  I  prefer  to  call  Spinal  Congestion ;  the  other 
of  slow  progress  as  compared  to  the  first,  and  characterized  by  accumula- 
tion rather  than  congestion,  which  I  will  speak  of  as  Subacute  Spinal 
Hypercemia. 

SPINAL   congestion. 

This  first  variety,  which  has  been  excellently  described  by  C.  B.  Rad- 
clifie,^  is  not  so  common  as  the  latter,  or  at  least  such  has  been  my  ex- 
perience. It  is  apparently  a  serious  condition,  and  may  somewhat  puzzle 
the  incautious  observer  who  may  mistake  it  for  some  one  of  the  organic 
diseases ;  but  it  has  certain  distinct  features  which  do  not  belong  to  the 
organic  neuroses,  and  I  think  there  should  be  no  difficulty  in  making  a 
diagnosis. 

Symptoms, — The  following  may  be  the  symptoms  of  an  attack  of 
Spinal  Congestion.  The  patient  probably  attracts  the  notice  of  his  friends 
by  telling  them  that  he  cannot  get  out  of  bed,  that  "  he  feels  as  if  he  were 
a  lump  of  lead,"  or  that  his  "  legs  and  arms  are  made  of  wood."  He  can- 
not move,  and  complains  repeatedly  of  his  utter  weakness ;  he  sighs,  and 
may  complain  that  the  room  is  close,  and  ask  to  have  a  window  opened ; 
he  is  able  to  appreciate  any  warm  substances  that  may  be  applied  to  the 
surface,  and  very  acutely  feels  pinching  or  the  prick  of  a  pin.  The  legs, 
he  says,  seem  very  cold,  and  he  requires  extra  covering ;  he  has  backache 
and  pains,  which  run  down  the  back  of  the  thighs,  but  pressure  does  not 
aggravate  the  pain  in  the  back,  which  is  only  relieved  by  lying  upon  the 
side  or  belly.  His  mind  is  clear,  but  he  is  restless,  suffers  for  want  of 
sleep,  and  is  extremely  uncomfortable.  The  functions  of  the  bowels  are 
perhaps  interfered  with,  there  being  constipation ;  but  there  is  never  in- 
continence of  urine  or  feces.  The  patient  becomes  paralyzed,  and  such 
paralysis  is  rather  sudden,  and  may  take  place  during  the  night,  or  per- 
haps more  gradually  after  the  appearance  of  pain  and  the  other  symptoms 
just  mentioned.  Reflex  action  is  abolished,  and  electro-muscular  contrac- 
tility is  increased. 

^  Article  in  Reynolds's  System  of  Medicine,  American  edition,  vol.  i.,  p.  942. 


256  DISEASES    OF   THE   SPINAL   COED. 

Radcliffe  calls  attention  to  the  wasting  of  the  muscles,  but  I  have  never 
seen  more  than  the  general  atrophy  which  would  occur  from  disuse  of  the 
lower  extremities,  for  the  patient  may  sometimes  lie  in  bed  for  months 
before  he  regains  the  lost  power.  The  duration  of  the  attack  rarely  ex- 
ceeds six  weeks,  but  there  is  a  possibility  of  a  second  attack.  The  paraly- 
sis is  generally  paraplegic,  though  it  may  be  irregular  in  its  onset,  one  leg 
or  arm  being  affected  before  the  other,  and  in  some  cases  it  is  general. 
The  spinal  pain  seems  to  be  increased  by  warmth,  and  the  patient  will 
feel  the  ice-bag  to  be  very  grateful  after  lying  upon  his  back  for  a  long 
time  on  a  warm  bed.  These  pains  are  as  a  rule  unaffected  by  movement, 
which  is  not  the  case  in  meningitis.  Bed-sores  as  a  feature  of  the  disease 
are  never  seen,  and  for  this  reason  no  suspicion  of  transverse  myelitis 
should  arise. 

SUBACUTE  SPINAL   HTPERiEMIA. 

Symptoms. — The  expressions  of  this  condition  are  very  slowly  mani- 
fested, and  are  very  often  mistaken  for  those  of  the  opposite  condition — 
anaemia  of  the  cord.  Tingling  and  heaviness  of  the  limbs  may  distress 
the  patient,  and  render  him  disinclined  to  take  exercise  or  remain  stand- 
ing for  any  length  of  time,  and  rnuch  of  his  want  of  energy  may  be  mis- 
taken for  laziness.  These  symptoms  are  especially  disagreeable  towards 
night  in  those  who  have  walked  much  during  the  day,  and  there  is  an 
uneasy,  tired  feeling,  which  is  only  relieved  by  change  of  position ;  and 
the  patient  seeks  in  vain  for  a  comfortable  place  to  rest  his  weary  limbs, 
and  only  finds  it  when  he  lies  upon  his  bed  or  sofa.  There  may  be  cuta- 
neous anaesthesia,  and  occasionally  hypertesthesia,  but  these  sensory 
troubles  are  by  no  means  common.  There  may  also  be  the  "constricting 
band,"  which  is  so  usually  suggestive  of  inflammation,  and  there  are 
vague  undefined  pains  in  the  thighs,  legs,  and  back,  which  are  extremely 
distressing.  The  temperature  is  lowered,  and  there  may  be  the  same  op- 
pressed breathing  which  is  such  a  marked  feature  of  the  acute  variety. 
Decided  paresis  is  rare,  and,  if  it  should  take  place,  it  is  nearly  always 
paraplegiform,  and  not  general,  as  it  may  occasionally  be  in  the  acute 
variety.  Should  this  be  the  case,  we  will  find  the  same  impaired  condi- 
tion of  reflex  excitability  and  normal  electro-muscular  contractility  which 
characterizes  the  more  active  variety  of  spinal  hypersemia.  The  tendency 
of  the  disease  is  to  disappear  under  proper  treatment,  and  in  its  worst 
forms  is  neither  a  grave  nor  lasting  trouble,  and  should  not  be  looked 
upon  with  alarm. 

Causes. — Women  seem  to  be  more  subject  to  the  first  form  than  men, 
and  this  is  probably  owing  to  irregularities  of  the  menstrual  condition. 
Uterine  conditions,  symptomatized  by  dysmenorrhcea  or  amenorrhcea,  may 
be,  and  often  are,  its  sole  causes.  Among  men,  the  long  continuance  of 
the  erect  position  seems  to  favor  the  gravitation  of  blood,  and  hypostatic 
hypersemia  of  the  spine  is  thereby  induced.  A  few  years  ago  I  satisfied 
myself  that  the  maintenance  of  the  erect  posture  for  a  long-continued 
period  resulted  in  a  great  deal  of  mischief.    My  investigations  were  chiefly 


SPINAL    HYPEREMIA.  257 

among  car-drivers,  who  were  compelled  to  stand  upon  the  platform  of  the 
city  railroad  cars  for  a  period  of  from  fourteen  to  sixteen  hours  daily. 
Spinal  congestion,  varicose  veins,  and  other  vascular  changes  were  com- 
mon and  serious  results ;  and  the  spinal  troubles  were  only  relieved  by  a 
long  rest.  A^enery,  alcoholic  intemperance,  and  malaria  are  often  causes 
of  spinal  hyperaemia ;  and  supj^ression  of  any  bloody  discharge,  such  as 
the  menses,  or  that  from  hremorrhoids,  will  be  apt  to  be  followed  by  more 
or  less  spinal  hyperemia.  Among  the  more  serious  causes  of  spinal  hyper- 
Eemia  may  be  mentioned  the  fevers.  The  spinal  congestions  which  usher 
in  some  of  the  exanthemata  are  symptomatized  by  back  pains,  etc.,  and 
do  not  properly  come  under  this  head  for  discussion ;  but  there  are  condi- 
tions which  play  a  most  important  part  in  the  etiology  of  spinal  conges- 
tion. The  malarial  cachexia  very  frequently  induces  a  condition  of  spinal 
hyperemia  which  misleads  the  observer,  and  the  true  cause  may  be  lost 
sight  of  under  the  periodic  character  of  the  painful  exacerbations.  This 
we  should  take  into  account  if  there  be  any  suspicion  of  malarial  poison- 
ing. I  have  seen  many  cases  of  very  decided  subacute  spinal  hypersemia 
which  followed  intermittent  fever..  The  disease  had  become  masked  to 
some  degree,  so  that  no  chill  was  complained  of;  but  the  individual  suf- 
fered more  at  some  parts  of  the  day  than  at  others,  and,  in  one  case  of 
this  kind,  there  was  some  loss  of  power,  which  was  increased  daily  at  a 
certain  hour,  and  never  seemed  to  disappear  entirely. 

Morbid  Anatomy  and  Pathology. — What  I  have  said  in  speak- 
ing of  cerebral  hypersemia  may  be  referred  to  in  explanation  of  the  ap- 
pearances met  with  in  spinal  congestion.  The  gray  matter  will  be  found 
to  be  quite  dark,  and  the  vessels  are  usually  enlarged.  The  white  matter 
is  often  of  a  pinkish  hue,  and  there  may  be  areas  of  hypersemia  which 
are  localized  ;  or  the  suffusion  may  be  general.  Microscopically  examined, 
the  cord  will  be  found  to  have  undergone  very  slight  changes,  and  they 
may  consist  only  in  increased  vascularity,  enlargement  of  capillaries,  and 
perhaps  some  exudation  beneath  the  vascular  sheaths.  The  vessels  of 
the  meninges  are  engorged,  and  there  are  to  be  observed  small  ecchy- 
mosed  spots,  or  occasionally  an  effusion  of  serum.  The  symptoms  of  the 
disease  result  from  pressure  upon,  and  irritation  of,  the  nervous  elements  ; 
and  the  violence  will  depend  upon  the  site  of  the  most  decided  hyperaemia. 
The  gray  substance,  when  subject  to  pressure  from  distended  vessels,  gives 
rise  to  the  pain  in  the  back,  and  cutaneous  hyper^esthesia,  as  well  as  the 
spasmodic  movements  which  symptomatize  the  aggravated  forms.  Spinal 
hypersemia  is  directly  induced  by  blood  defects  and  disease  of  other  organs, 
and  it  is  favored  by  the  anatomical  structure  of  the  parts  concerned. 
The  tortuous  course  of  the  veins,  and  the  absence  of  valves,  are,  accord- 
ing to  Jaccoud,  among  the  latter.  The  stasis  of  blood  in  their  interior, 
which  follows  forced  respiration,  such  as  must  be  caused  by  violent  exer- 
tion, or  by  disease  of  the  thoracic  and  abdominal  organs  which  to  some 
degree  arrests  the  return  of  venous  blood  from  the  cord,  favors  hypersemia. 

Diagnosis. — Spinal  meningitis,  myelitis,  and  spinal  irritatign  are  the 
diseases  with  which  it  may  be  confounded. 
17     • 


258  DISEASES    OF    THE    SPINAL    COED. 

1st.  The  spinal  pains  of  meningitis  are  increased,  as  has  been  shown, 
by  movement,  which  is  not  the  case  in  spinal  congestion,  and  there  is  a 
muscular  rigidity  in  the  first-mentioned  disease  which  does  not  exist  in 
this. 

2d.  Myelitis  differs  from  spinal  congestion  for  the  reason  that  complete 
anaesthesia,  wasting,  loss  of  electric  contractility  and  sensibility,  reflex- 
excitability,  incontinence  of  urine  and  feces,  and  bedsores,  belong  to  the 
former. 

3d.  Spinal  irritation  (anremia?).  The  spinal  tenderness  is  increased 
by  pressure  in  ansemia,  and  there  is  no  cutaneous  tingling.  There  are 
troubles  of  other  organs,  and  generally  a  variable  amount  of  hysteria. 

Prognosis. — The  chances  for  recovery  are  very  good,  provided  active 
measures  are  at  once  taken  to  reduce  the  fulness  of  the  spinal  vessels.  If 
the  condition  becomes  a  chronic  one,  even  then  much  may  be  done  to  im- 
prove the  abnormal  state  of  the  circulation.  In  many  cases,  however,  it 
precedes  myelitis,  particularly  when  it  takes  the  slow  course  which  I  have 
described  as  subacute  spinal  hypersemia,  or  it  may  lead  to  atrophy  ;  but 
this  tissue-change  is  more  directly  induced  by  spinal  anaemia. 

Treatment. — The  local  application  of  cups,  counter-irritants,  and 
cold  may  all  be  practised ;  and,  in  addition,  we  may  use  either  hydro- 
bromic  acid,  the  bromides,  or  ergot,  in  full  doses  ;  or  belladonna  till 
some  of  the  toxic  effects  are  produced.  It  is  never  well  to  prescribe 
alcohol,  strychnine,  or  iron  in  these  cases,  or  any  agents  which  in- 
crease central  irritability,  and  I  have  witnessed  disastrous  effects  from 
their  use.  The  Turkish  bath  is,  I  think,  one  of  the  best  adjuvants  to 
these  forms  of  treatment.  As  a  local  application  to  the  spine,  I  have  di- 
rected the  patient  to  procure  a  strip  of  adhesive  plaster,  which  should 
extend  from  the  lower  cervical  vertebra  to  the  sacrum.  This  is  to  be 
warmed  and  dusted  with  red  pepper,  and  then  applied  to  the  back.  It  is 
a  very  excellent  form  of  counter-irritant,  and  may  be  worn  for  some  time. 
The  cups  may  be  wet  or  dry,  according  to  the  severity  of  the  case,  al- 
though I  prefer  the  former.  Should  there  be  any  pronounced  symptoms; 
these  are  to  be  used  two  or  three  times  a  week.  It  must  be  borne  in  mind 
that  general  treatment,  such  as  the  re-establishment  of  fluxes  which 
have  been  interrupted,  and  the  regulation  of  the  functions  of  the  excre- 
tory organs,  is  to  be  undertaken  as  early  as  possible;  for,  like  cerebral 
hypersemia,  the  condition  is  nearly  always  one  that  is  secondary.  As  an 
immediate  remedy,  one  of  Chapman's  bags  may  be  filled  with  ice-water 
and  applied  to  the  back  for  ten  or  fiften  minutes  at  a  time,  or  the  ether 
spray  will  answer  the  same  purpose. 


SPINAL     IRRITATION.  259 

SPINAL  lERITATION". 

(spinal  anemia  ?) 

Synonyms. — Ischeraie  de  la  moelle.     Anasmie  de  la  moelle. 

The  brothers  GriflBn^  were  the  first  to  describe  this  interesting  affection, 
and  since  the  appearance  of  their  first  paper  in  the  London  Medical  and 
Physical  Journal  in  1829,  very  little  has  been  added  to  our  knowledge  of 
this  condition,  which  was  fully  considered  so  many  years  ago.  The  pa- 
thology of  the  affection  was  by  the  Griffins  supposed  to  consist  primarily 
in  an  irritation  of  the  sympathetic  ganglia,  and  they  divided  their  cases 
into  three  varieties,  viz.,  those  in  which  the  cervical,  dorsal,  or  lumbar 
portions  of  the  sympathetic  nerves  were  involved.  In  later  years  other 
observers,  consider  the  affection  due  to  an  anaemic  condition  of  the  cord, 
and  go  so  far  as  to  attempt  to  localize  anaemia  of  the  different  columns, 
I  am  disinclined  to  agree  with  them,  not  only  because  I  believe  that  spinal 
irritation  depends  sometimes  upon  hypersemia,  but  I  think  that  this  condi- 
tion is  due  more  to  a  loss  or  abnormality  of  cell- functions.  I  am  therefore 
disposed  to  adopt  the  views  of  the  Griffins,  and  consider  "  spinal  irritation" 
to  be  a  condition  due  to  a  primary  perversion  of  the  functions  of  the 
sympathetic  system,  or  to  a  secondary  ischaemic  state,  and  that  in  some 
parts  of  the  cord  both  abnormalities  of  circulation  exist.  Dr.  V.  P. 
Gibney  advanced  the  view  before  the  American  Neurological  Association 
(session  of  1877)  that  spinal  irritation  was,  in  the  majority  of  cases,  a 
meningeal  affection,  and  was  usually  the  result  of  injury  of  some  kind. 
In  support  of  this  theory  he  brought  forward  a  number  of  cases,  all  of 
them  of  great  interest.  I  am  strongly  inclined  to  accept  Dr.  Gibney's 
explanation,  but  not  in  its  entirety.  Spinal  irritation  is  very  probably 
due  not  only  to  affections  of  the  cord  alone,  but  to  the  meninges  as  well, 
as  the  symptoms  of  spinal  tenderness  suggest.  That  a  great  many  cases 
arise  from  disordered  functions  of  other  organs,  there  can  be  no  doubt,  and 
the  history  of  injury  is  very  often  absent. 

Symptoms. — The  indications  of  spinal  irritation  are  quite  varied, 
but  there  are  several  which  are  distinctly  pathognomonic  One  of  these 
is  spinal  tenderness.  If  the  observer  makes  firm  pressure  with  his  thumb 
at  different  points  over  the  intervertebral  spaces,  he  may  cause  the  patient 
to  wince  where  a  painful  point  receives  the  pressure.  These  tender  spots 
may  be  either  in  the  cervical,  dorsal,  or  lumbar  regions,  but  more  often 
the  cervical  or  dorsal.  Sometimes  the  skin  is  so  hyperaesthetic  at  these 
places  that  the  pressure  of  the  clothing  is  sufficient  to  cause  the  wearer 
great  discomfort ;  and  such  patients,  be  they  women,  are  fidgety  and  irri- 
table. Pressure  made  at  certain  points  may  be  followed  by  pain,  not  only 
in  the  region  pressed  upon,  but  at  distant  parts ;  for  instance,  in  one  of 
Griffin's  cases  pressure  made  over  the  dorsal  vertebra  was  followed  by 

^  Observations  on  Functional  Affections  of  the  Spinal  Cord  and  Ganglionic  System 
of  Nerves,  etc.,  by  Wm.  and  Daniel  Griffin.    London,  1843. 


260  DISEASES    OF    THE    SPINAL    COKD. 

pain  in  the  sternum.  Pain  also  of  a  darting  or  lancinating  character  fol- 
lows such  pressure,  and  sometimes  when  the  lumbar  region'is  its  seat  there 
may  be  twinges  which  travel  down  the  crural  and  sciatic  nerves.  So, 
too,  may  there  be  radiation  of  pam  about  the  chest  when  the  dorsal  por- 
tion of  the  cord  is  subjected  to  this  procedure,  Pressure  over  the  cervi- 
cal intervertebral  spaces  produces  vertigo,  headache,  and  nausea.  With 
irritation  of  the  cervical  region,  vertigo  is  quite  pronounced.  Memory 
is  afiected,  and  hysterical  manifestations  are  quite  common  ;  while  in- 
somnia and  headache,  disordered  vision  and  facial  neuralgia,  vomiting, 
and  respiratory  troubles  are  all  prominent  symptoms.  The  headache  is 
connected  with  soreness  of  the  scalp,  and  is  of  a  neuralgic  character,  and 
the  fifth  nerve  is  so  extensively  affected  that  toothache,  faceache,  and  deep 
orbital  pains  when  they  occur,  are  almost  intolerable.  As  an  evidence  of 
disordered  function  of  the  fifth  nerve,  there  may  be  trophic  changes  in  the 
cornea,  such  as  ulceration,  and  there  is  in  some  cases  keratitis  Cervico- 
brachial  neuralgia  may  exist  in  addition  to  the  facial  neuralgia,  and  may 
be  either  one-.sided  or  bilateral,  and  pressure  made  upon  the  cervical  ver- 
tebrae may  greatly  aggravate  the  neuralgia.  Diplopia,  amaurosis,  and 
other  visual  troubles  are  annoying  in  the  extreme,  and  the  intense  hyper- 
sesthetic  state  of  the  organs  of  special  sense  may  give  rise  to  hallucina- 
tions of  sight  or  hearing.  There  is  not  rarely  photophobia  of  a  distress- 
ing character,  so  that  the  individual  is  obliged  to  stay  in  a  darkened  room. 
Deafness  is  an  occasional  symptom,  and  ringing  in  the  ears  is  an  indica- 
tion of  cerebral  anosmia  co-existent  with  the  spinal  troubles.  The  gastric 
mucous  membrane  may  be  in  an  extremely  irritable  condition,  so  that 
the  food  is  speedily  ejected,  and  with  the  vomiting  there  is  nausea  with 
vertigo.  The  spinal  origin  of  this  symptom  may  be  satisfactorily  proved 
by  applying  a  blister  to  the  painful  spot.  Various  x'espiratory  and  cardiac 
irregularities  are  quite  constant  accompaniments  of  spinal  irritation. 
Among  these  are  attacks  of  dyspepsia,  angina,  palpitation,  coughing,  or  a 
sense  of  pressure  and  discomfort  in  breathing,  asthma,  etc.  Ui'inary 
troubles  may  exist  when  the  morbid  spinal  condition  is  situated  lower 
down,  and  often  ovarian  neuralgia.  Convulsive  movements  of  the  legs 
and  obstinate  constipation  swell  the  list  of  symptoms.  A  form  of  paraple- 
gia, usually  of  an  hysterical  nature,  but  sometimes  so  C(mstant  as  to  seem 
to  be  dependent  upon  some  organic  lesion,  occasionally  symptomatizes  the 
disease.  There  is  even  lowered  temperature,  though  the  patient  may 
complain  of  subjective  sensations  of  warmth;  but  the  paraplegia  is  never 
attended  by  any  evidences  of  the  real  condition  Avhich  follows  myelitis. 
The  action  of  the  bladder  and  rectum  is  normal,  and  the  electro-muscular 
contractility  and  reflex  excitability  are,  if  anything,  increased,  and  the 
ansesthesia  or  hypera^sthesia,  if  it_  exists,  is  quite  unimportant. 

The  following  history  was  given  to  me  in  the  patient's  words,  and  is  so 
graphic  that  I  consider  it  worthy  of  reproduction : — 

1st  year,  1867.     There  was  some  cerebral  anaemia.      Inability  to  think 
consecutively,  or  to  do  anything  that  required  looking  after  ;  constant 


SPINAL    IRRITATION.  261 

nausea  and  dizziness  ;  a  burning  in  head  and  spine,  and  an  occasional 
deep  seated  and  momentary  pain  in  the  head ;  an  excessive  demand  for 
pure  air  ;  extreme  hyperaesthesia  of  skin  ;  sleeplessness  ;  worried  feeling 
in  the  ovaries. 

2d  year,  1868.  Head  symptoms  slightly  improved ;  body  grew  weak 
and  tremulous  ;  felt  as  if  starving  to  death,  though  with  good  appetite 
for  nourishing  food.  Nausea  not  constant,  but  occurring  every  night  be- 
tween nine  and  ten,  and  lasting  about  an  hour. 

Zd  year,  1869.  Mind  grew  painfully  active,  it  was  impossible  to  stop 
thinking,  asleep  or  awake ;  gradual  loss  of  use  of  arms  and  legs,  with 
distressing  jerkings  of  latter;  hysterical;  light  and  sound  almost  intole- 
rable. 

4ih  year,  1870.  Commenced  walking  after  lying  in  bed  seven  months. 
Dizziness,  sleeplessness,  tremor ;  burning  in  head  and  spine  continued. 

bth  year,  1871.    Same  as  fourth  year,  with  some  alleviation. 

Qth  year,  1872.  Material  changes  were  more  sleep,  arrested  condition 
of  brain,  and  tremor  not  constant. 

1th  year,  1873.  Dizziness,  which  had  been  constant  from  the  beginning, 
ceased.  Ability  to  converse,  and  listen  to  any  amount  of  reading,  attend 
lectures,  etc.  Pain  or  distressed  feeling  in  head  most  of  time.  More  de- 
pression of  spirits  than  ever  ;  sleep  full  of  nightmare.  Neuralgic  pain  ; 
appetite  indifferent ;  bowels  torpid ;  menses  irregular  and  overabundant, 
extremely  painful,  and  prostrating. 

The  patient  was  29  years  old,  and  married.  She  is  in  appearance 
anaemic,  evidently  of  a  strumous  diathesis,  and  somewhat  hysterical.  Her 
pupils  are  dilated,  and  there  is  decided  muscular  asthenia-  She  cannot 
read,  and,  when  she  attempts  to  do  so,  there  is  a  peculiar  dizziness,  or,  as 
she  very  pertinently  calls  it,  a  "nausea  of  the  brain."  If  reading  is  per- 
sisted in,  the  dizziness  is  excessive,  and  there  is  ultimately  vomiting.  Her 
headache  is  vertical,  and  some  uneasiness  is  produced  by  pressure  made 
over  cervical  vertebrae.  Her  urine  is  copious  and  abundant,  and  con- 
tains phosphates.  Constipation  is  persistent  and  obstinate.  At  my  re- 
quest Dr.  Loring  examined  her  eyes  with  the  ophthalmoscope,  and  found 
atrophy  of  the  left  optic  disk. 

Jan.  30,  1874.  Strychnia,  iron,  and  phosphoric  acid  were  given,  and 
absolute  rest  required  and  enjoined;  and  one  month  later  she  returned, 
feeling  very  much  improved.  It  is  possible  for  her  to  read  two  hours  at 
a  time  without  being  fatigued,  and  her  spirits  are  very  much  improved ; 
her  depression  has  somewhat  disappeared,  and  she  sleeps  much  better." 
A  curious  feature  of  this  woman's  disease  was  excessive  somnolency 
during  the  day,  and  it  was  often  necessary  to  use  violent  measures  to 
arouse  her  from  her  very  profound  sleep.  During  the  evening  she  became 
very  animated  and  bright,  talking  brilliantly  upon  all  subjects,  and  it 
was  not  until  midnight  before  she  again  felt  a  disposition  to  sleep.  In 
her  case  evidently  the  monorrhagia  was  the  cause  of  the  anaemia. 

Causes. — The  victims  of  spinal  irritation  are  nearly  always  women, 
and  very  rarely  men.  It  may  safely  be  said  that  nine-tenths  of  all  the 
cases  are  females.  It  rarely  occurs  before  puberty,  but  after  that  time  may 
make  its  appearance,  and  then  is  generally  dependent  upon,  or  associated 
with,  irregular  or  profuse  menstruation.  It  not  rarely  begins  at  the 
menopause,  but  is  more  often  of  earlier  origin.  Hereditary  predisposition 
seems  to  have  much  to  do  with  its  development,  and  various  mental  causes 


262  DISEASES    OF    THE   SPINAL     CORD. 

play  an  important  part  in  its  production ;  care,  worry,  and  overwork 
being  among  these.  Various  debilitating  diseases,  childbirth,  and  bad 
habits,  may  be  enumerated  as  additional  causes. 

Morbid  Anatomy  and  Pathology. — Spinal  irritation  being  a 
functional  disease,  it  is  impossible  to  find  any  pod-mortem  indications, 
unless  they,  perhaps,  are  foci  of  low  inflammatory  action,  such  as  thick- 
ening of  the  neuroglia,  or  simple  atrophy. 

As  to  its  pathology,  I  have  already  expressed  my  vi  ews  in  regard  to 
the  probability  of  both  hyperaemic  and  ancemic  conditions  as  pathological 
factors.  It  is  impossible,  I  am  convinced,  to  locate  the  point  of  irritation 
in  either  of  the  columns,  and  any  attempt  to  do  so  is  an  impossible  refine- 
ment of  diagnosis.  We  may  approximate  its  seat  by  the  region  of  ten- 
derness, and  the  predominance  of  special  groups  of  symptoms ;  and  this 
is  all  that  I  believe  to  be  possible.  Spinal  irritation  may  undoubtedly 
result  from — 1,  reflected  irritation;  2,  impoverished  blood-supply;  3, 
local  changes  dependent  upon  disease  of  adjacent  tissues. 

The  labors  of  Brown-Sequard,  Bernard,  and  lately  Lauder  Brunton, 
have  showed  satisfactorily  the  intimate  relation  between  the  sympa- 
thetic and  cerebro-spinal  systems  ;  and  the  o  bservations  of  the  former 
are  especially  valuable  because  of  their  pathological  bearing.  Not  only 
may  distant  organs  send  irritating  impressions  to  the  cord,  to  be  followed 
by  vaso-raotor  stimulation,  contraction,  and  subsequent  relaxation  o  f  the 
vessels,  but  the  intra-spinal  circulation  of  impure  blood  may  produce 
local  irritation,  imperfect  nutrition  of  the  nerve-cells,  shrinkage  of  the 
nervous  tissue,  and  oedema  of  the  perivascular  spaces.  The  chain  of  in- 
hibitory ganglia,  described  in  such  a  beautiful  manner  by  Brunton, 
places  in  close  relation  the  different  parts  of  the  cerebro-spinal  axis,  so 
that  there  is  nearly  always  a  disturbance  of  several  organs  when  the 
harmony  is  affected. 

The  vascular  cramp  of  Nothnagel  will  account  for  various  ischsemic 
conditions  in  certain  parts,  while  circulation  in  neighboring  districts  may 
be  perfectly  normal.  Bidder  ^  has  also  shown  that  complete  alteration  of 
vascular  calibre  is  impossible,  so  that  at  best  there  is  contraction  but  at  a 
certain  point,  while  the  other  part  of  the  vessel  may  be  dilated. 

Bidder's  experiments  also  demonstrated  that  excitement  or  exaggerati  on 
of  function  may  exist  with  depressed  function  at  the  same  time,  in  a 
compound  organ. 

It  is  therefore  reasonable  enough  to  consider  that  spinal  irritation  is 
not  altogether  dependent  upon  spinal  ansemia. 

The  production  of  special  symptoms  is  explained  by  the  involvement 
of  sympathetic,  cranial,  or  spinal  nerve-roots.  The  headache  may  result 
from  cerebral  anaemia,  as  may  also  the  mental  and  hysterical  symptoms ; 
while  the  visceral  disturbances  arise  from  sympathetic  derangement  of 
the  abdominal  organs.     The  pain  resulting  from  pressure  is  due  to  im- 

^  Die  Keflexe  sines  der  sensiblen  Nerven  du  Herzen  auf  die  motorische  du  Blutge- 
fasse. 


BPINAL    IRRITATION.  263 

pressions  conducted  to  tlie  over-sensitive  centre  by  the  cutaneous  nerves. 
It  is  almost  unnecessary  to  allude  to  the  production  of  spasms,  reflected 
pain,  and  the  numerous  dyssesthesia. 

Diagnosis. — Spinal  congestion,  spinal  meningitis,  and  incipient  in- 
flammation of  the  cord  may  suggest  themselves  to  the  observer.  As  to 
the  first,  differential  diagnosis  is  often  impossible,  unless  there  be  actual 
paresis.  The  absence  of  great  spinal  tenderness  is  also  an  element  in  di- 
agnosis. Spinal  meningitis  is  connected  with  tenderness,  but  it  is  not 
aggravated  so  much  by  pressure  as  by  muscular  movements.  There  are 
also  present  muscular  spasms  of  a  painful  character. 

Myelitis  in  the  beginning  is  attended  by  waist  constriction,  which  is  too 
marked  to  be  mistaken ;  and  besides  paralysis  of  motion  and  sensation, 
there  is  atrophy,  as  well  as  progressive  symptoms.  The  presence  of  gas- 
tric disorders,  which  are  so  marked  in  nearly  all  cases  of  spinal  irrita- 
tion ;  of  headache,  and  great  languor,  a  generally  depraved  physical 
state,  and  the  existence  of  uterine  trouble,  should  all  be  taken  into 
account. 

Griffin  alluded  to  several  other  disorders  likely  to  produce  some  of  the 
symptoms  of  spinal  irritation.  These  are  rheumatism,  which  is  sometimes 
causative  of  spinal  soreness,  and  various  acute  diseases,  which,  however, 
present  so  many  symptoms  of  a  distinct  character  as  to  do  away  with  any 
chance  for  mistake  in  diagnosis.  The  pain  of  rheumatism  is  generally 
so  severe  and  absorbing  that  the  patient's  mind  is  constantly  directed  to 
it,  while  affections  of  the  joint  usually  coexist. 

Prognosis  and  Treatment. — If  the  patient  be  promptly  taken  in 
hand  it  is  often  possible  to  cure  the  disease,  but  I  am  inclined  to  consider 
well-established  spinal  irritation  the  most  discouraging  and  intractable 
functional  neurosis  that  is  to  be  met  with.  Commonly  connected  with 
ovarian  or  uterine  derangement,  it  defies  the  best- directed  efforts  of  the 
physician ;  and,  if  the  factor  cannot  be  removed,  the  patient  becomes  a 
confirmed  invalid.  It  is,  therefore,  proper  in  all  cases  to  search  for  the 
cause,  and  in  three-quarters  of  the  female  cases  it  will  be  found  in  the  pel- 
vis. If  there  be  general  anaemia,  or  some  other  depraved  condition  of  the 
system,  we  are  to  "build  up^"  our  patient  with  cod-liver  oil  and  tonics, 
and  a  very  excellent  one  is  the  following : — 

E,  Ferri  et  amraon  citratis,  Jiij*  5 

Tr.  gentianse,  5iv. — M, 

Sig, — A  teaspoonful  in  water  after  eating. 

Phosphorus,  either  in  the  form  of  Thompson's  solution,  or  the  phos- 
phuretted  oil,  quinine,  pyrophosphate  of  iron,  Horsford's  acid  phosphates, 
the  syrup  of  the  combined  phosphates,  are  all  in  order.  Nutritious  food 
and  extract  of  malt  are  to  be  given,  and  a  liberal  use  of  stimulants  is 
strongly  recommended.  Strychnine  sometimes  does  good,  and  at  others 
a  great  deal  of  harm  ;  and  in  cases  where  there  is  very  severe  pain,  I  pre- 
fer other  remedies. 


264  DISEASES    OF    THE    SPINAL    COKD. 

Opium  in  small  doses  is  often  of  great  value,  and  its  effects  are  imme- 
diate and  excellent.  External  counter-irritation,  either  by  the  actual 
cautery  applied  on  the  painful  points,  a  blister,  or  some  irritating  oint- 
ment, is  advised,  and  if  vomiting  be  present,  a  blister  on  the  epigastrium, 
subsequently  dusted  with  morphia,  allays  the  irritability  of  the  stomach. 
I  have  used  with  success,  and  would  recommend,  galvanism  (the  descend- 
ing current),  the  positive  pole  being  placed  upon  the  nucha,  and  the  ne- 
gative in  the  groin.  Applications  lasting  five  or  ten  minutes  every  day, 
or  every  other  day,  are  sufficient. 

Galvanization  of  the  cervical  sympathetic  is  an  important  form  of  aux- 
iliary treatment.  Heat  and  cold  alternately  applied  to  the  spine  are  fol- 
lowed by  excellent  results  ;  or  Chapman's  ice-bags,  filled  with  hot  water, 
and  placed  in  contact  with  the  spine  for  fifteen  or  twenty  minutes  daily, 
are  beneficial. 

Open-air  exercise,  Turkish  baths,  and  massage,  all  help  the  patient ; 
and  Mitchell's  rest-treatment,  already  described,  is  one  of  our  best  modes 
of  treatment  in  confirmed  cases. 


MYELITIS.  26h 


CHAPTER   IX. 

DISEASES  OF  THE  SPINAL  CORD  (Continued) 
INFLAMMATION  OF  THE  SPINAL  CORD— MYELITIS. 

Synonyms. — Myelitis.  Myeliteaigue,  chronique.  Riickeumarkeul- 
ziindung. 

Definition. — Inflammation  of  the  spinal  cord,  usually  attended  l).y 
paralysis  of  motion  and  sensation  below  the  seat  of  the  spinal  lesion,  hy 
involuntary  stools  and  incontinence  of  urine,  and  by  absence  of  reflex  ex- 
citability and  electric  contractility  in  the  paralyzed  parts,  and  a  tendency 
to  extension  upwards,  results  in  death  in  a  very  short  time  from  paralysis 
of  the  intercostal  muscles,  especially  should  the  pathological  condition  be 
an  acute  one.  Inflammation  of  the  spinal  cord  may  extend  across  the 
cord,  when  it  is  called  transverse  myelitis;  or  longitudinally,  when  the 
terms  ascending  or  descending  are  applied.  The  features  of  an  attack  of 
transverse  myelitis,  which,  as  an  acute  condition,  is  so  rapid  in  develop- 
ment that  it  suspends  the  functions  to  a  great  extent  of  the  columns  of  the 
cord,  so  that  we  get  a  simultaneous  or  rapid  impairment  of  the  conductors 
of  motion  and  sensation,  and  the  disordered  functions  of  organs  inner- 
vated by  nerves  coming  from  the  cord  below  the  level  of  the  diseased  por- 
tion ;  or,  on  the  other  hand,  the  integrity  of  the  different  conductors  of 
the  cord  may  be  gradually  impaired,  so  that  many  months  or  years  may 
elapse  before  the  morbid  process  extends  across  a  plane,  destroying  suc- 
cessive parts.  In  the  other  forms  in  which  the  inflammatory  process  tra- 
vels upwards  or  downwards,  the  loss  of  function  is  more  irregular.  Still 
another  form  exists,  in  which  the  periphery  is  affected,  with  or  without 
meningeal  complication. 

ACUTE   MYELITIS. 

Symptoms. — The  disease  begins  rather  suddenly,  generally  with  pain 
in  the  back,  which  is  aggravated  by  pressure,  and  an  uneasy  sense  of 
tightness  about  the  body.  These  unpleasant  sensations  may  be  preceded 
by  formication  and  tingling  of  the  feet,  some  loss  of  power,  and  the  de- 
velopment of  more  or  less  fever,  during  which  the  temperature  may  be 
very  much  elevated.  This  is  especially  the  case  when  the  upper  part  of 
the  cord  is  involved.  These  symptoms  are  followed  in  several  hours,  or 
after  a  day  or  two,  by  loss  of  power  in  the  lower  limbs  and  by  an  aggra- 
vation of  the  spinal  pain.  The  patient  will  find  it  impossible  to  j)ass  his 
urine,  and  if  he  is  not  relieved  by  a  catheter  will  suffer  great  distress  ;  or 


266  DISEASES    OF    THE    SPINAL    CORD. 

there  may  be  final  relaxation  of  the  sphincter,  and  it  may  flow  from  him 
without  his  knowledge.  These  symptoms  are  sometimes  presented  before 
a  physician  is  called  in,  and  at  his  visit  there  may  be  complete  paralysis 
of  the  lower  extremities.  The  surface  of  the  limbs  is  cold  and  utterly  de- 
void of  sensation,  and  the  soles  may  be  tickled  or  the  muscles  pinched 
Avithout  any  attempt  being  made  upon  the  part  of  the  patient  to  withdraw 
his  feet.  This  reflex  excitability,  however,  is  not  always  lost  in  the  be- 
ginning, but  may  be  present  when  the  onset  of  the  disease  is  gradual,  and 
the  patient  is  entirely  unconscious  of  the  occurrence  of  these  movements. 
If  a  heated  substance  be  applied  to  the  back,  it  will  be  found  that  its 
presence  will  not  be  appreciated  below  the  point  of  spinal  inflammation, 
but  when  it  is  passed  over  the  diseased  tract  the  pain  is  greatly  increased. 
Above  this  level,  normal  sensibility  exists,  and  the  degree  of  heat  is 
readily  perceived.  The  attention  of  the  physician  is  attracted  by  the  am- 
moniacal  odor  of  the  urine,  which,  as  has  been  stated,  may  flow  from  the 
patient  without  his  knowledge,  and  the  contents  of  his  rectum  may  pass 
away  in  the  same  manner.  Hyperresthesia  is  an  exceptional  late  feature, 
but  it  may  form  one  of  the  initial  symptoms  in  conjunction  with  trembling 
of  the  limbs.  After  the  paralysis  takes  place,  the  temperature  is  lowered 
several  degrees,  and  circulation  is  very  defective.  At  the  end  of  a  week 
there  may  be  indications  of  the  upward  extension  of  the  spinal  inflamma- 
tion if  it  be  progressive,  and  it  is  sometimes  recognized  by  the  tendency 
to  priapism  and  the  distress  in  breathing,  and  with  these  there  nmy  be 
hiccough  and  hurried  respiration,  the  number  perhaps  reaching  48  in 
the  minute.  Bedsores  form  over  the  sacrum,  and  there  is  every  appear- 
ance of  approaching  dissolution.  The  skin  becomes  clammy,  and  there 
may  be  rigors  ;  while  the  pulse  grows  small,  fluttering,  and  the  voice  very 
weak,  and  ultimately  the  patient  dies,  his  mind  remaining  clear  to  the 
end.  If,  however,  the  structural  alteration  progresses  upward,  it  is  very 
probable  that  the  mode  of  death  will  be  asphyxia.  As  exceptional  in- 
stances, cases  have  been  recorded  in  which  there  was  myelitis  of  the  upper 
part  of  the  cord,  with  complete  paralysis  of  the  upper  extremities,  while 
the  lower  limbs,  the  bladder,  and  rectum  were  not  affected,  and  other 
equally  rare  forms  are  occasionally  not^d.  When  the  dorsal  portion  of 
the  cord  is  the  seat  of  inflammatory  action,  the  respiratory  symptoms  are 
immediate,  and  the  breathing  becomes  embarrassed  at  once.  The  pneu- 
monia occurring  so  often  in  a  late  symptom  of  myelitis  is  undoubtedly  of 
nervous  origin,  and  commonly  indicates  the  implication  of  the  medulla. 
The  pneumonia  is  complicated  by  some  bronchial  trouble.  Vulpian'  and 
Arnozan'  lately  have  given  consideration  to  the  connection  between  spinal 
and  pulmonary  diseases,  under  certain  circumstances,  and  the  former  is 
of  the  opinion  that  the  sympathetic  roots  of  the  intercostal  nerves  are  in- 
volved. 

The  prominent  symptoms  of  this  interesting  disease  may  be  summed 
XI  p  as — 

1  Maladies  de  la  Moelle,  p.  185.  ^Des  lesions  trophiques,  etc.,  p.  198.    Paris,  1880. 


MYELITIS.  267 

1.  Paraplegia  of  sudden  or  gradual  origin,  attended  by  anaesthesia  and 
analgesia,  but  usually  preceded  by  dyssestbesia  of  various  kinds,  or  actual 
hyper?esthesia.  It  may  be  accompanied  in  the  beginning,  according  to 
Radcliffe,^  who  has  observed  this  symptom  in  severe  cases,  by  "  uncontrol- 
lable restlessness."  Paraplegia  is  nearly  always  the  form  of  lost  power, 
though  in  rare  cases  there  is  hemiplegia.  There  may  be,  in  exceptional 
cases,  variations  in  sensibility,  the  symptoms  of  ansesthesia  being  absent 
when  the  anterior  columns  are  alone  partially  affected.  Again,  in  other 
cases  one  leg  may  be  paretic  and  the  other  anaesthetic.  The  onset  of 
the  paraplegia  may  be  very  sudden,  and  the  disease  prove  rapidly  fatal. 
Jaccoud^  has  seen  one  case  in  which  the  paraplegia  developed  in  thirty-six 
hours  from  the  commencement  of  the  disease.  Eighteen  hours  afterwards, 
the  autopsy  revealed  a  purulent  meningo-myelitis  of  the  entire  lumbar 
and  part  of  the  dorsal  segments  of  the  cord.  The  extent  ot  the  paraplegia 
is  of  course  governed  by  the  seat  and  course  of  the  myelitis.  If  the  lum- 
bar portion  of  the  cord  be  destroyed,  the  lower  extremities,  and  the  mus- 
cles of  the  abdomen  and  sphincters  will  be  paralyzed  ;  if  the  myelitis 
extends  so  that  the  dorsal  portion  and  the  cilio-spinal  centre  are  involved, 
the  arms  are  paralyzed,  and  pupillary  changes  with  irregularity  of  cardiac 
functions  are  produced.  When  the  lesion  is  still  higher,  and  the  cervical 
portion  of  the  cord  is  involved,  there  may  be,  in  addition  to  all  these 
forms  of  paralysis,  various  difficulties  in  swallowing,  speech,  and  respira- 
tion, and  the  patient  dies  from  asphyxia. 

2.  Reflex  excitability  is  generally  abolished  entirely,  or  impaired  to  a 
great  extent.  Occasional  exaggeration  is  seen  in  the  earliest  stages,  or 
when  the  myelitis  involves  limited  regions,  especially  the  lumbar  segment. 
Jaccoud  says  :  "  Durant  la  periode  d'exageration  (hyperkinesie  reflexe) 
le  segment  lombaire  soustrait  a  I'influence  du  cerveau  manifestait  son 
action  proper  avec  la  puissance  accre  qu'elle  tirait  de  son  isolement ;  du- 
rant la  periode  d'abolition  (akindsie  reflexe)  cette  action  propre  ou  spinale 
est   andantie   parceque  les  elements   qui  en   sont  dou^s  sont  detruits." 

3.  Electric  contractility  and.  sensibility  are  abolished  or  greatly  lowered. 
The  only  exception  to  this  rule  is  when  the  reflex  excitability  is  in- 
creased. 

4.  Muscular  atrojjhy  as  a  result  of  severance  of  spinal  innervation 
sometimes  follows.  This  may  take  place  in  from  four  to  six  weeks.  The 
atrophy  is  general,  and  is  of  course  attended  by  absence  of  electro-mus- 
cular contractility  and  by  coldness  of  the  surface. 

5.  Bedsores  and  other  evidences  of  defective  cutaneous  innervation  are 
present.  The  skin  becomes  swollen,  or  there  may  be  at  first  great  dry- 
ness and  redness,  or  oedema  at  the  points  subjected  to  pressure.  A  hard, 
red  bullous  nodule  may  form,  and  subsequently  break  down,  and  some- 
times large  patches  of  tissue  are  rapidly  destroyed.     According  to  Ash- 


^  Op.  cit.,  p.  314.  2  Path.  Interne,  vol.  i.  p.  315. 


268  DISEASES    OF     THE    SPINAL    CORD. 

urst  bedsores  are  more  frequent  when  the  lesions  of  the  cord  are  low 
down. 

In  hemiparaplegia  when  the  lesion  is  unilateral  the  bedsore  is  also  uni- 
lateral and  upon  the  side  opposite  the  lesion,  and  bearing  in  mind  the 
law  of  Brown-S<iquard,  loss  of  power  and  vaso-motor  paresis  with  hyper- 
sesthesia  upon  the  side  of  the  lesion  and  anaesthesia  on  the  opposite  side, 
the  bedsore  appears  on  the  ausesthetic  side. 

Arnozan  reports  a  case  in  which  a  monoplegia  affecting  one  limb  was 
followed  by  bedsores  upon  both  buttocks,  that  upon  the  paralyzed  side 
being  one  and  a  half  centimetre  in  its  largest  diameter,  while  that  upon 
the  other  was  the  size  of  a  silver  dollar.  The  paralysis  was  at  first 
supposed  to  be  cerebral  in  origin,  but  the  occurrence  of  violent  lum- 
bar pain  and  atrophy  supported  its  spinal  character.  Cases  are  on  record 
where  a  brisk  arthritis  developed  upon  the  sound  extremity,  while  upon 
the  other  a  bedsore  appeared. 

Brown-Sequard  according  to  Arnozan  believes  that  the  occurrence  of 
bedsores  is  most  frequent  in  cases  where  thei'e  is  incontinence  of  urine. 

6.  The  sphincters  are  paralyzed,  the  urine  is  intensely  alkaline,  the  walls 
pf  the  bladder  being  paralyzed,  and  as  a  consequence  a  certain  amount 
of  urine  remains  in  that  organ  in  a  decomposed  state,  and  rapidly  induces 
an  alkaline  reaction  in  that  which  may  collect  in  addition  before  it  is 
discharged.  Brown-Sequard  is  inclined  to  consider  that  this  condition 
of  affairs  is  pathognomonic  of  disease  of  the  dorsal  region,  and  I  infer 
holds  that  it  is  essentially  a  nervous  symptom,  Leroy  d'Etiolles^  has 
alluded  to  cases  of  paraplegia,  the  so-called  ])(t,raplcgie  urinaires  which 
follow  bladder  troubles  in  which  cystitis  with  purulent  and  decomposed 
urine,  and  perhaps  ulcerated  thickening  and  local  paralysis  of  the  vesical 
walls  are  found.  Frequent  catheterization  or  sounding  aggravates  the 
trouble,  and  a  myelitis  may  result  either  as  a  reflex  nervous  trouble,  or 
as  a  result  of  absorption.  Radcliffe  alludes  to  a  reflex  spasm  of  the 
sphincter  ani  which  occasionally  occurs  in  this  disease,  but  this  symptom 
is  so  exceptional  as  to  need  but  passing  comment.  The  paralysis  of  this 
muscle  is  ordinarily  so  complete  as  to  be  followed  by  the  almost  constant 
escape  of  softened  feces  and  watery  discharges.  The  sphincter  ani  some- 
times however  shows  an  abnormal  amount  of  reflex  excitement.  A 
favorite  subject  with  those  who  endeavor  in  courts  of  law  to  prove  spinal 
disease  and  obtain  heavy  damages,  is  the  possible  atrophy  of  the  male 
parts  of  generation.  Such  a  consequence  of  myelitis  is  exceedingly  rare, 
though  Curling  has  admitted  that  wasting  of  the  testicles  may  follow. 
Arnozan  quotes  Klebs,  who  says  that  often  when  wounds  of  the  lumbar 
cord  are  near  the  genito-spinal  region,  or  in  connection  with  certain 
paraplegias  the  spermatozoa  disappear  and  there  is  cellular  degeneration. 

7.  Increase  of  temperature  and  piulse  call  for  no  special  mention.  Oc- 
curing  with  paralysis  of  the  lower  extremities  and  no  loss  of  conscious- 
ness they  can  symptomatize  but  two  acute  spinal  affections,  myelitis  and 

^  Des  Parapl^gies,  1856. 


MYELITIS.  269 

meningitis.  The  spasmodic  movements  of  the  latter  disease,  however, 
are  not  observed  in  myelitis,  so  that  it  possesses  at  least  some  diagnostic 
importance.  The  temperature  varies  from  the  normal  standard  to  104° 
or  105°,  and  the  pulse  may  reach  160. 

8.  The  constricting  hand  sensation  or  parsesthesia,  which  is  more  marked 
in  myelitis  than  any  other  form  of  spinal  disease,  is  generally  likened  by 
the  patient  to  that  which  might  result  if  a  tight  cord  were  tied  about  the 
body.  It  is  usually  located  at  the  waist,  and  sometimes  when  it  is  not 
complained  of  may  be  developed  by  a  sharp  blow  on  the  back,  or  by  the 
application  of  an  electrode  to  the  spine. 

CHRONIC   MYELITIS. 

Symptoms. — The  disease  sometimes  takes  a  more  slow  course.  The 
paralytic  symptoms  are  much  less  sudden  in  their  .onset,  and  occur  one 
after  another,  so  that  the  extension  of  the  inflammation  may  be  sometimes 
traced.  For  some  time,  perhaps  for  several  months,  there  may  be  dis- 
orders of  sensation,  such  as  tingling  spinal  pain,  and  the  "  constricting 
band."  The  perception  of  pain  in  the  affected  limbs,  though  not  entirely 
abolished,  is  greatly  impaired. 

Charcot,^  Romberg,^  and  Cruveilhier^  have  called  attention  to  the 
curious  mistakes  sometimes  made  by  patients  in  locating  painful  sensa- 
tions. Pain  following  the  pinching  of  one  leg  is  referred  to  the  other, 
and  the  painful  impression  may  take  several  seconds  to  reach  the  senso- 
rium.  In  one  of  Romberg's  patients  pressure  upon  the  toe  was  referred 
to  the  hip.  Cruveilhier's  experiments  demonstrated  that  an  interval  of 
from  fifteen  to  thirty  seconds  elapsed  sometimes  before  any  sensation  was 
excited,  and  that  the  impression  had  to  be  made  several  times  before  it 
was  perceived.  Electric  contractility  is  perhaps  increased,  and  reflex 
excitability  is  very  much  exaggerated,  and  may  be  followed  by  very 
violent  movements.  Thus,  when  a  warm  bottle  is  sometimes  applied  to 
the  feet,  though  the  temperature  is  not  so  high  as  to  cause  discomfort  to 
a  healthy  person  who  touches  it,  the  patient's  legs  will  be  violently  drawn 
up  ;  this  always  suggests  a  meningeal  complication.  Dyssesthesise  are  re- 
ferred to,  and  pains  in  the  joints  and  bones,  especially  aggravated  by 
humidity  of  the  atmosphere,  are  spoken  of  by  the  patient.  The  paralysis 
of  motion  is  much  less  extensive  than  it  is  in  the  acute  form  and  in  the 
beginning ;  and  spasms  of  the  muscles  of  the  lower  extremity  are  quite 
violent.  Subsequently,  however,  they  disappear  as  the  loss  of  power  be- 
comes more  complete,  and  at  this  time  there  are  lowered  temperature  and 
electric  irritability  instead  of  the  primary  exaggerated  condition.  The 
bladder  and  rectum  are  subsequently  affected,  and  various  degrees  of  de- 
ranged function  may  be  noticed.     One  of  my  patients  is  obliged  to  pass 

1  Op.  cit. 

*  Manual  of  the  Nervous  Diseases  of  Man,  Syd.  Trans.,  vol.  i.  p.  267,  et  seq. 

'  Anatomie  Pathologique,  livre  xxxviii.  p.  9. 


270  DISEASES    OF    THE    SPINAL    CORD. 

his  water  every  ten  or  fifteen  minutes,  and  his  bowels  are  so  constipated 
as  to  require  an  injection  every  day.  The  individual  generally  loses  his 
desire  for  sexual  gratification  if  the  disease  is  at  all  advanced,  though  in 
the  beginning  there  may  be  a  marked  disposition  to  erection.  Muscular 
atrophy  takes  place  if  the  anterior  horns  be  affected. 

An  increase  in  the  tendinous  reflex  is  shown  very  markedly,  especially 
if  the  gray  matter  of  the  cord  be  affected.  The  dorsal  clonus  is  quite 
violent  and  the  slightest  tap  upon  any  of  the  muscles  causes  a  series  of 
convulsive  movements  of  great  violence.  The  jarring  of  the  patient  will 
even  give  rise  in  some  instances  to  an  irregular  coarse  tremor  of  the 
lower  extremities,  which  may  last  for  several  seconds.  The  invasion  of 
the  lateral  columns  is  symptomatized  by  contractures,  great  spastic  rigidity 
and  discomfort.  The  legs  and  thighs  may  be  so  drawn  up  that  the  heels 
may  make  painful  pressure  upon  the  buttocks,  and  the  contact  of  the 
knees  when  the  adductors  are  the  seat  of  contracture  give  rise  to  skin 
changes,  and  even  ulcers.  I  have  repeatedly  found  a  "glazed"  boggy 
skin  readily  pitting  upon  pressure,  though  the  skin  is  usually  of  a  muddy 
white  color  and  either  clammy  or  even  dry  and  scurfy.  Ferrier  discov- 
ered a  peculiarity  in  this  disease  due  to  skin  changes  ;  that  if  a  silver 
coin  was  rubbed  upon  its  edge  a  dark  line  would  remain  for  some  time. 

Causes. — The  common  causes  of  myelitis  are  injury,  syphilis,  acute 
diseases,  exposure,  and  extension  of  meningeal  disease.  Falls  and  blows 
upon  the  back  are  the  origin  of  the  majority  of  cases,  but  I  consider 
syphilis  to  have  a  very  great  deal  to  do  with  even  these,  when  often  it  is 
not  suspected.  Meningeal  thickening  or  acute  meningitis  undoubtedly 
play  an  important  part  as  mechanical  factors ;  and  in  many  cases  re- 
ported, disease  of  the  vertebrae  has  been  found  to  produce  the  myelitis. 
Potts'  disease  seems  to  be  a  fruitful  cause  of  myelitis  and  usually  of  a 
very  serious  variety.  When  so  produced  the  atrophy  and  contractures 
of  the  limbs  and  active  motor  phenomena  point  to  a  decided  implication 
of  the  antero-lateral  columns  of  the  cord.  In  such  cases  it  is  rare  for  the 
meninges  to  escape  inflammatory  action,  and  as  a  consequence,  the  symp- 
toms of  meningitis  are  added  to  those  of  the  myelitis. 

The  existence  of  a  large  aneurism  of  the  aorta,  may  also  by  erosion, 
prove  to  be  a  source  of  injury  to  the  cord,  and  in  some  cases  it  is  neces- 
sary to  use  great  caution  in  making  a  diagnosis.  In  a  case  recently  under 
observation,  the  gradual  development  of  an  irregular  paraplegia  was  ac- 
cidentally found  to  be  associated  with  the  presence  of  an  abdominal 
aortic  aneurism  of  large  size,  which  produced  a  great  deal  of  pain.  There 
is  a  variety  of  myelitis  which  deserves  the  most  careful  study,  because  of 
its  medico-legal  importance,  and  I  allude  to  that  following  spinal  concus- 
sion. Cases  of  "railway  spine"  are  so  common  in  these  days  of  railroad 
accidents,  and  there  is  so  much  danger  of  malingering,  that  I  must  add  a 
word  of  advice  to  those  who  have  occasion  to  go  into  courts  of  law  as  ex- 
perts. That  inflammation  of  the  cord  may  follow  a  concussion,  I  think 
there  can  be  no  manner  of  doubt,  and  some  of  the  cases  of  Erichsen  sup- 
port this  theory  ;  there  are  many  others,  however,  in  which  hysteria  plays 


MYELITIS.  271 

SO  important  a  part  as  to  lead  the  examiner  astray,  unless  he  is  prepared  to 
avoid  the  error  of  accepting  the  patient's  recital  of  subjective  symptoms 
as  conclusive.  I  do  not  think  that  any  jury  should  give  damage  unless 
some  physical  signs  of  actual  spinal  disease  are  present. 

The  production  of  spinal  inflammation  from  injury  which  does  not  pro- 
duce external  wounds,  need  not  be  of  immediate  appearance.  It  may  be 
masked  at  first,  but  with  due  care  it  should  be  detected  much  earlier  than 
Erichsen  is  disposed  to  grant.  When  present,  the  symptoms  are  con- 
spicuous because  of  their  irregularity  and  behaviour.  Of  the  persons 
applying  to  the  courts  for  redress,  there  are  few  who  have  suffered  from 
early  acute  symptoms,  but  the  cases  are  peculiar  and  therefore  difiicult 
to  examine.  In  many  of  them  unequal  atrophy  of  the  limbs,  increased 
tendinous  reflex  activity,  and  ocular  changes  are  present,  while  all  are 
likely  to  complain  of  dysaesthesia,  loss  of  memory  and  mental  feebleness, 
and  incapacity  for  work.  In  those  who  sham,  it  will  be  found  that  there 
is  an  utter  absence  of  physical  changes,  the  tendinous  reflex  is  neither 
exaggerated  nor  absent,  the  muscles  respond  well  to  electric  stimulation, 
and  the  story  of  aches  and  pains  is  out  of  proportion  with  any  possible 
kind  of  spinal  trouble.  The  loss  of  memory  and  enfeeblement  for  brain 
work  rarely  stand  the  test  of  critical  examination,  and  the  patient's  an- 
tecedent history  does  not  bear  out  his  story. 

Venereal  excesses,  onanism,  and  continued  dissipation  are  direct  causes 
which  should  not  be  overlooked. 

Morbid  Anatomy  and  Patholo^. — When  the  vertebral  canal 
is  opened,  the  investing  membranes  slit  up,  and  the  cord  exposed,  it  will 
be  found  to  be  greatly  changed  in  color  and  consistency  at  certain  parts, 
and  it  may  be  diffluent  and  of  a  pinkish  color.  Scattered  throughout  the 
softened  portion  collections  of  blood  may  sometimes  be  found,  and  these 
are  more  often  in  the  greatly  altered  gray  substance,  from  which  the  dis- 
ease seems  to  have  started.  At  other  points  there  may  be  discovered  evi- 
dences of  slight  vascular  changes,  such  as  occur  in  the  red  stage  of  cerebral 
softening.  There  may  be  adhesions  of  the  meninges  to  the  cortex  or  col- 
lections of  pus  between  them.  In  the  more  slow  form  of  degeneration 
(chronic  myelitis)  the  process  may  not  be  so  widespread,  limited  areas 
being  only  affected.  As  the  result  of  either  form  there  may  be  an  atrophic 
condition  of  the  cord,  or  an  actual  hardness  which  we  shall  presently  speak 
of  in  our  consideration  of  sclerosis.  The  microscopical  appearances  are 
the  following :  the  vessels  are  enlarged,  varicose,  or  broken,  and  are  sur- 
rounded by  effused  hsematine  ;  the  nerve- tubes  are  swollen,  irregular,  and 
disrupted,  and  the  axis  cylinders  substituted  by  oil-globules  or  granular 
debris ;  and  the  nerve-cells  may  have  been  broken  down  and  become 
simple  granular  masses  of  a  round  or  ovoid  shape  (Gluge's  corj)uscles). 
Fat  globules  may  be  found  scattered  here  and  there  if  the  cord  of  an  ad- 
vanced case  is  examined  ;  and  the  connective  tissue  may  be  found  to  be 
thickened  and  increased  in  density.  Pus-corpuscles  may  also  be  seen.  Dr. 
R.  T.  Edes,  who,  with  Dr.  S.  G.  Webber,  of  Boston,  have  done  so  much 
pathological  work  in  the  field  of  myelitis,  presented  a  case  to  the  American 
Neurological  Association,  which  presented  a  not  uncommon  microscopical 


272  DISEASES   OF    THE    SPINAL    CORD. 

appearance.  The  myelitis  had  lasted  four  mouths,  and  while  the  white 
matter  was  unaffected  Edes  found  the  gray  nervous  substance  to  contain 
little  vacuoles  in  the  anterior  horns.  The  ganglia  cell  processes  were 
shrunken  and  broken.  Putnam,  of  Boston,  had  seen  a  case  presenting 
the  same  appearance,  and  in  his  observations,  there  were  collections  of 
fat  in  the  ganglion  cells,  and  he  was  disposed  to  regard  this  deposit  as  in- 
dication of  an  earlier  stage  of  the  same  process,  which  ended  in  Edes' 
case  by  the  formation  of  vacuoles.  In  fact,  he  found  openings  at  a  lower 
level. 

Jaccoud^  speaks  of  two  kinds  of  myelitis — inycUte  en  foyer  and  myelite 
central.  In  the  first  form  the  meninges  will  be  found  to  be  injected  and 
adherent  to  the  nervous  substance,  and  the  nodules  or  patches  may  be 
several  centimetres  in  length  or  smaller.  These  foyers  are  quite  distinctly 
separated  from  each  other  by  healthy  tissue,  and  when  one  is  removed 
the  nidus  in  which  it  has  formed  is  seen  to  be  in  quite  normal  condition. 
The  anterior  columns  and  anterior  nerve-roots  are  often  found  to  be  in- 
volved ;  and  the  latter  are  the  seat  of  "  petites  nodosites  exuberantes." 
When  the  disease  assumes  a  chronic  form,  these  softened  patches  may 
become  encysted  as  in  cerebral  softening.  The  central  form,  as  its  name 
implies,  begins  in  the  gray  matter,  and  generally  extends  longitudinally. 

^Dr.  Gowers  gives  a  most  comprehensive  diagram  for  the  localization 
of  spinal  disease  which  I  have  reproduced  (Fig.  37).  It  is  founded  upon 
anatomical  and  pathological  data,  and  will  enable  the  student  to  fix  the 
level  of  the  lesion  by  a  consideration  of  the  anatomical  significance  of  the 
symptom. 

Diagnosis. — It  is  necessary  to  exclude  spinal  meningitis,  locomotor 
ataxia,  spinal  tumors,  and  spinal  congestion. 

Spinal  Meningitis. — What  I  have  already  said  in  a  previous  article 
renders  further  consideration  unnecessary. 

Locomotor  Ataxia. — There  is  no  paralysis  of  motion  in  this  disease, 
but  rather  an  increased  muscular  activity,  which  is  expressed  by  the  vio- 
lent manner  in  which  the  patient  throws  out  his  foot ;  while  in  chronic 
myelitis  he  drags  one  foot  after  another.  The  neuralgic  pains  in  the  ex- 
tremities are  absent  in  myelitis  ;  while  in  locomotor  ataxia  they  are  mark- 
ed symptoms.  In  myelitis  there  are  none  of  the  paralyses  of  cranial 
nerves  so  commonly  found  with  sclerosis  of  the  posterior  columns ;  the 
tendon-reflex  is,  moreover,  usually  absent  in  locomotor  ataxia. 

Spinal  Tumors. — The  presence  of  a  spinal  tumor  may  sometimes  pro- 
duce pressure  upon  the  cord,  and  give  rise  to  some  of  the  symptoms.  The 
slow  development  of  the  growth  is,  however,  attended  by  corresponding 
slowly  appearing  symptoms,  and  the  paralysis  is  not  complete.  The 
chance  for  doubt  as  to  the  condition  arises  when  secondary  myelitis  results 
from  such  a  tumor. 


*  Path.  Interne;  ed.  2me,  vol.  i.  p.  310. 

-  The  Diagnosis  of  Disease  of  the  Spinal  Cord,  W.  K.  Gowers,  M.D.,  F.R.C.P., 
London,  1880,  p.  52. 


MYELITIS. 
Fig.  37. 


273 


MOTOR. 


St. -mastoid 
I"  Trapezius 
I  1 

J  Diaphragm 

.    >Serratus 
j- j  Stioulderl 


Hand 

(ulnar  lowest) 


Intercostal 

Muscles 


J   f- Abdominal 
Muscles 


Flexors,  hip 
Extensors,  knee 


t  Adductors  ~1 
I 


SENSORY. 


>-Neck  and  Scalp 
/Neck  and  Shoulder 


Shoulder 

Arm 

Hand 


REFLEX. 


Uip 


Abductors 

Extensors(?)  J 
Flexors,  knee  (?) 

Muscles    of    leg 
movins;  foot 


Perineal    and  Anal 
J     muscles 


.Front  of  Thorax 


>-  Ensiform  area 


Abdomen 
j- (Umbilicus  loth) 


I  Buttock,  upper 
j      part 

Groin  and  scrotum 
(front) 

f  outer  side 

Thigh    J.  front 


Scapular 


Epigastric 


Abdominal 


1  '(_  inner  side 

Leg,  inner  side 
f  Buttock,  lower 
part 


Back  of  Thigh 

and  I  .  «^««P*  , 
,FootJ  ^'I'^^'^Pai"* 


I  Perineum  and 

y    Anus 

"j  Skin  from  coccyx 
y    to  anus 


Cremasteric 
T 
I 
Knee  reflex 


-  Gluteal 


Ankle  clonus 
Plantar 


Fig.  37. —  Diagram  and  Table  showing  the  Appkoximate  Relation  to  the  Spinal  Coeds  or  the 
Various  Motor,  Sensory,  and  Reflex  Functions  or  the  Spinal  Coed.  {From  anatomical  and 
pathological  data.)     (Gowers.) 

18 


274  DISEASES    OF    THE    SPINAL    CORD. 

Spinal  Congestion. — These  serious  symptoms  of  myelitis  are  never  pro- 
duced by  anything  but  a  degenerative  process,  and  there  are  rarely  bed- 
sores, alkaline  urine,  or  the  profound  disturbances  of  sensation  or  motion 
which  characterize  myelitis. 

Prognosis. — In  every  case  much  depends"  upon  the  nature  of  the 
cause,  and  the  extent  of  the  cord  involved.  If  there  be  a  traumatism,  of 
course  this  gives  the  disease  a  serious  character,  and  death  may  occur  in 
a  few  days. 

Acute  myelitis  may  run  an  exceedingly  rapid  course  carrying  off  the 
patient  in  two  or  three  weeks,  and  in  such  cases  there  are  usually  febrile 
symptoms.  Webber^  says,  "  It  is  not  always  easy  to  decide  whether  a 
case  of  myelitis  should  be  called  acute  or  chronic.  The  integrity  of  the 
whole  cord  is  so  essential  to  its  proper  function  that  if  only  a  small  por- 
tion is  affected  there  are  irregular  and  defective  actions  in  all  that  part 
below,  and  perhaps  in  2:)arts  above.  If  an  acute  affection  of  one  segment 
is  recovered  from  with  permanent  injury  of  the  diseased  portion,  the  result- 
ing symptoms  are  permanent,  and  there  is  chronic  derangement  of  function. 
Inflammation  may  begin  in  an  acute  form  in  the  lumbar  enlargement, 
and  then  advance  upwards  slowly,  yet  pathologically,  with  the  same 
characters  in  each  segment  of  the  cord  ;  as  no  vital  parts  are  affected, 
life  is  prolonged,  and  the  cases  seem  to  be  chronic  in  time,  while  being 
acute  pathologically.  In  fatal  cases,  then,  the  chronicity  or  acuteness 
depends  upon  whether  vital  centres  are  attacked  early  or  late  in  the  dis- 
ease." 

If  the  myelitis  result  from  pressure  from  diseased  and  displaced  verte- 
brae, the  result,  though  more  distant,  is  equally  bad.  Very  few  cases  re- 
cover entirely  from  chronic  myelitis,  and  in  those  that  do,  the  lesion  must 
either  be  due  to  syphilis,  or  be  very  limited 

The  reparative  action  of  a  bed-sore  is  a  valuable  index  of  the  central 
lesion.  I  have  repeatedly  witnessed  the  most  varying  and  rapid  changes, 
either  on  the  result  of  an  improvement,  or  the  reverse  in  the  diseased 
cord. 

Treatment. — Counter-irritation,  cold,  and  ergot  are  useful  in  the 
early  stages  of  the  acute  disease.  The  former  may  be  produced  by  the 
actual  cautery,  but  care  should  be  taken  not  to  burn  extensively,  as  the 
tissues  are  too  ready  to  slough.  Ice-bags  may  be  used,  and  the  patient 
should  be  laid  on  a  water-bed,  and  kept  as  clean  as  possible  ;  the  thighs 
and  nates  being  washed  occasionally  with  salt  and  water,  or  with  hot  and 
cold  water  alternately.  The  iodide  of  potassium,  with  belladonna,  should 
be  given  internally.  Should  the  case  be  one  of  slow  development,  I  pre- 
fer the  use  of  ergot  in  half-drachm  doses  thrice  daily ;  or  we  may  use  the 
bromides. 

The  sesqui-chloride  of  iron  seems  to  have  enjoyed  deserved  popularity 
in  England,  and  it  is  preferred  by  Radcliffe  to  the  iodide  of  potassium. 
In  one  case  I  obtained  very  excellent  results  with  the  tincture  of  the 

^  Boston  Medical  and  Surgical  Journal,  vol.  cii.,  No.  7. 


ACUTE    ASCEXDIXG    PARALYSIS.  275 

chloride  of  iron..  Phosphorus  and  cod-liver  oil,  those  valuable  builders 
of  nervous  tissue,  may  be  employed  here  with  every  hope  that  they  will 
do  good.  In  chronic  myelitis  they  are  especially  serviceable,  and  small 
and  frequent  doses  of  strychnine  are,  in  addition,  useful.  The  use  of  the 
phosphate  of  silver  has  been  so  often  followed  by  good  results  in  recent 
cases,  that  I  believe  it  should  be  tried,  not  only  in  this,  but  in  other 
organic  diseases.  It  seems  to  have  a  noticeably  good  influence  upon  the 
bladder,  and  in  several  cases  I  have  found  the  patient  was  able  to  hold 
his  water  after  its  use. 

There  are  forms  of  auxiliary  treatment  which  not  only  increase  the 
comfort  of  the  patient,  but  go  far  towards  ameliorating  his  disease.  One 
of  these  is  the  assumption,  if  possible,  of  a  position  which  shall  favor 
the  determination  of  the  blood  from  the  spine.  Brown-Sequard  has  re- 
commended that  the  patient  should  lie  upon  his  side  or  belly,  with  his 
legs  somewhat  lower  than  the  rest  of  the  body.  I  have  found  that  wash- 
ing out  the  bladder  with  a  dilute  solution  of  carbolic  or  nitric  acid,  or 
chlorate  of  potash,  prevents  the  disposition  to  cystitis  which  there  very 
often  is  in  myelitis.  Warmth  of  the  limbs,  established  by  wrapping  them 
in  cotton  batting,  with  a  covering  of  oil-silk,  or  the  new  India-rubber 
tissue-paper,  opposes  contractions,  and  stimulates  the  cutaneous  circula- 
tion ;  while  application  of  the  faradic  current,  and  the  employment  of 
massage,  help  the  patient  to  a  great  extent.  The  electric  brush  should  be 
used  faithfully  every  day,  and  it  is  better  that  the  physician  should  make 
his  own  electrical  application,  than  trust  it  to  a  nurse  or  attendant.  The 
descending  galvanic  current  of  moderate  strength  may  also  be  used  daily. 

ACUTE  ASCEIs^DmG  PARALYSIS. 

Synonyms. — Landry's  Paralysis.  Disseminated  Neuritis  (Gros). 
Progressive  Paralysis  (Graves).  Paralysis  ascendante  aigue  (Dejer- 
ine). 

Definition  and  Symptoms. — A  form  of  advancing  paralysis  de- 
pending upon  a  rapidly  developing  central  disease  which  affects  succes- 
sive portions  of  the  cord  in  its  upward  course  until  it  reaches  the  medulla, 
when  death  occurs.  From  the  absence  of  any  distinct  anatomical  change 
it  cannot  be  said  to  be  a  myelitis.  Westphall  could  not  find  any  changes 
whatever  in  cases  observed  by  him,^  and  Erb  quotes  various  authors 
whose  investigations  have  had  the  same  result. 

The  disease  begins  by  vague  sensory  changes  referred  to  the  extremi- 
ties. There  is  an  anaesthesia  of  the  finger  tips,  so  that  the  individual 
does  not  xeadUy  feel  small  things,  and  finds  some  difficulty  in  buttoning 
his  clothes.  He  is  indisposed  to  walk  and  grows  easily  tired,  and  this 
weakness  in  from  one  to  six  weeks  increases  to  actual  paresis,  so  that  he 
becomes  paraplegic  and  cannot  walk  at  all.  The  disease  seems  to  be 
confined  almost  exclusively  to  the  motor  tracts  of  the  cord,  and  as 
the  disease  reaches  a  higher  level  we  find  a  gradual  loss  of  power  in 

1  Abstract  by  Dr.  J.  .T.  Putnam  in  Boston  Medical  and  Surgical  Journal,  Sept.  4, 
187Q,  from  original  "  Contribution  a  I'Histoire  des  Xevrites,  Paris,  1879.'' 


276  DISEASES   OF    THE    SPINAL    CORD. 

the  parts  above.  The  muscles  of  the  abdomen  become  weakened,  and 
the  functions  of  the  bladder  and  bowels  are  much  hindered,  a  resulting 
atony  taking  place.  The  patient,  through  weakness  of  the  muscles  of 
the  trunk,  is  unable  to  hold  himself  upright  (Erb),  and  as  the  intercos- 
tal muscles  become  affected  we  find  various  respiratory  troubles,  such  as 
shallowness  of  breathing  and  dyspncea.  The  arms  in  turn  are  paralyzed, 
and  the  muscles  of  the  neck  involved,  and  when  the  medulla  becomes 
aflTected  the  symptoms  of  bulbar  paralysis  are  presented,  and  the  patient 
ultimately  dies  of  asphyxia.  Sensory  troubles  are  very  light,  and  occur 
only  when  the  motor  symptoms  are  well  marked. 

As  negative  symptoms  may  be  mentioned — 1.  Absence  of  atrophy, 
except  the  slight  amount  resulting  from  inaction.  2.  No  abnormal  in- 
crease of  reflex  excitability  either  cutaneous  or  tendinous.  3.  No  im- 
paired susceptibility  of  the  muscles  to  electric  stimulation.  4.  No  con- 
tractions are  ever  present.  Gros  alludes  to  the  varieties  of  the  disease 
with  reference  to  the  duration  and  severity. 

"  There  are  three  varieties :  (1)  the  acute,  usually  fatal  in  the  course 
of  three  weeks,  often  before  the  muscular  atrophy  commonly  met  with 
has  had  time  (it  is  inferred)  to  develop  itself;  (2)  the  subacute,  ending 
either  in  partial  recovery  or  in  death  in  the  course  of  six  months  to  a 
year,  and  liable,  in  the  former  event,  to  relapse ;  (3)  the  chronic,  the 
most  common  form,  lasting  many  years,  but  liable,  also,  to  burst  out  into 
the  acute  variety  at  any  time.  The  onset  of  the  disease  is  commonly 
rapid,  and  not  infrequently  marked  by  a  short  febrile  attack."  ^ 

Gros  considers  the  disease  a  centripetal  affection,  and  calls  attention  to 
the  tenderness  at  the  peripheral  ends  of  the  nerves. 

Causes. — The  causation  of  the  disease  is  not  known,  and  all  kinds 
of  theories  have  been  advanced  —  cold,  intoxication,  the  poison  of 
typhoid,  diphtheria  and  small-pox  have  been  alluded  to  as  elements  in  its 
production,  and  syphilis  has  been  suggested  as  a  factor.  The  history  of 
metallic  poisoning  would  suggest  the  possibility  that  in  some  cases  it 
might  play  an  important  part  in  the  genesis  of  the  disease.  I  know  of  one 
patient  who  died  from  acute  ascending  paralysis  as  a  result  of  lead  poisoning, 
and  it  is  very  probable  that  certain  forms  of  acute  paralysis  following  in 
the  wake  of  the  exanthematous  fevers  might  reasonably  be  supposed  to 
produce  a  peripheral  neuritis. 

Pathology. — The  cord,  brain  and  medulla  have  been  repeatedly 
examined  but  without  success,  so  far  as  the  discovery  of  lesions  were  con- 
cerned. The  sympathetic  nervous  system  is  probably  primarily  affected, 
judging  from  what  Gros  has  said,  and  like  some  other  form  of  spinal 
disease,  in  which  primary  changes  appear  in  isolated  groups  of  muscles, 
and  which  are  supjjosed  by  modern  investigators  to  be  due  to  terminal 
lesions,  so  may  this  affection  have  a  peripheral  origin.  Dr.  Grainger 
Stewart'  in  an  admirable  paper  upon  a  rare  form  of  ascending  neuritis, 
which,  in  many  respects,  resembles  the  disease  under  consideration,  only 

^  Edinburgh  Medical  JourDal,  April,  1881,  p.  878. 


ANTERO-SPINAL    PARALYSIS    OF    INFANTS.  277 

in  the  trouble  lie  describes  there  is  an  affection  of  sensory  nerve  fibres, 
as  well  as  motor,  and  there  are  nerve  changes.  From  the  general  char- 
acter of  the  trouble  he  is  inclined  to  believe  the  origin  and  pathology  of 
the  two  diseases  to  be  alike.  This  would  point  to  the  peripheral  origin 
of  acute  ascending  paralysis. 

Diagnosis. — It  is  necessary  to  distinguish  this  disease  from  a  myelitis 
which,  if  transverse,  is  symptomatized  by  decided  affection  of  motion  and 
sensation,  and  is  attended  by  atrophy  and  decided  disturbances  of  the 
pelvic  organs,  such  as  incontinence.  Adult  spinal  paralysis  is  much  more 
apt  to  be  mistaken  for  the  disease  under  consideration,  than  anything 
else,  but  here  there  is  atrophy  which  is  so  decided  and  irregular  as  to  be 
unlike  the  slight  wasting  of  acute  ascendiug  paralysis.  Gros  speaks  of 
the  difficulty  of  distinguishing  the  disease  from  simple  spinal  menin- 
gitis, which  even  after  all,  may  be  connected  with  the  affection  under  con- 
sideration. So  far  as  my  own  experience  goes  there  is  enough  mus.cular 
rigidity  and  spastic  trouble  to  make  a  diagnosis,  at  least  in  the  commence- 
ment. 

Prognosis. — The  duration  of  the  disease  may  be  very  short ;  even 
three  or  four  days  may  be  sufficient  for  it  to  run  its  fatal  course.  Wilks^ 
says,  "  In  seeing  such  cases  I  am  reminded  of  a  spark  alighting  on  a  piece 
of  touch  paper,  and  the  fire  running  through  its  length  until  the  whole 
is  quickly  consumed." 

Erb  speaks  more  hopefally,  and  refers  to  Landry,  who  cured  eight  out 
of  ten  cases.  In  some  cases  the  disease  may  come  to  a  stand  still  for 
a  time,  and  have  a  fresh  outbreak,  which  carries  off  the  patient.  It  is  pro- 
bable that  the  morbid  process,  whatever  it  is,  may  be  of  an  exceedingly 
light  grade,  and  affect  the  cord  to  a  limited  degree. 

Treatment. — Active  counter-irritation  seems  to  have  been  most  suc- 
cessful. This  may  be  produced  by  the  actual  cautery  or  the  application 
of  croton  oil.  Cupping,  faradization  by  the  wire  brush,  and  cold  douches, 
certainly  have  done  good  in  the  German  cases.  Of  course  the  use  of 
remedies  and  food  calculated  to  build  up  the  nervous  system,  are  to  be 
employed,  and  among  these  are  phosphorus  and  the  fats.  Cod-liver  oil, 
the  iodide  of  potassium,  or  the  syrup  of  the  iodide  of  iron,  may  be  given 
alone  or  in  combination. 

ANTERO-SPINAL  PARALYSIS  OF  II^FANTS. 

Synonyms. — Paralysie  essentielle  de  I'enfance  (Rilliet  and  Barthez); 
Infantile  Paralysis  (Radcliffe  Volkman,  and  others)  ;  Paralysie  atro- 
phique  de  I'enfance,  Organic  Infantile  Paralysis  (Hammond)  ;  Infantile 
Spinal  Paralysis  (Seguin)  ;  Spinale  Kinderlahmung  (Heine). 

Definition. — This  form  of  paralysis  may  be  described  as  a  condition 
usually  characterized  by  a  primary  febrile  stage,  a  secondary  paralysis 
generally  of  the  lower  extremities,  and  a  tertiary  atrophy.  The  paralysis 
is  incomplete,  as  sensibility  is  never  lost. 

^  Diseases  of  the  Nervous  System,  p.  225. 


278  DISEASES    OF    THE    SPINAL    CORD. 

Symptoms. — The  disease  is  marked  by  a  febrile  onset  of  greater  or 
less  severity,  attended  by  restlessness,  malaise,  and  pains  in  the  joints  or 
back,  and  there  may  be  rigors ;  or  in  some  instances  the  loss  of  motor 
power  is  preceded  by  one  or  more  paroxysms  of  convulsions.  This  febrile 
state  is  by  many  mothers  mistaken  for  "  teething,"  "  worms,"  or  other  un- 
important childish  troubles,  and  it  is  not  till  the  development  of  paralysis 
that  any  alarm  is  created.  This  symptom  appears  within  two  or  three 
days  from  the  beginning  of  the  fever,  and  may  take  place  at  night.  The 
only  condition  of  disturbed  sensibility  is  one  of  hypersesthesia,  which, 
however,  is  not  a  constant  symptom. 

Sinkler^  has  collected  a  number  of  cases  in  which  he  has  noted  the  form 
of  invasion  of  the  disease.  He  found  that  the  paralysis  took  place  sud- 
denly, that  is,  with  prodromata  in  but  6  of  108  cases,  while  Dr.  M.  P. 
Jacobi'^  noted  this  form  of  invasion  in  12  of  163  cases  that  she  had 
collected.     The  modes  of  onset  are  the  following : — 

1.  The  child,  while  playing,  suddenly  drops  palsied. 

2.  The  child  may  be  paralyzed  at  night. 

3.  Fever,  but  no  convulsions ;  rapid  loss  of  power. 

4.  Convulsions,  followed  by  sudden  paralysis.  Sinkler  reports  but 
one  case  of  this  kind,  and  but  two  in  which  convulsions  followed  the  par- 
alysis). 

5.  The  paralysis  preceded  by  one  for  the  exanthemata,  or  by  whoop- 
ing-cough. 

6.  Gradual  development,  perhaps  limping  at  first,  and  afterwards  com- 
plete paralysis,  but  no  acute  symptoms. 

In  this  exceedingly  valuable  lecture,  Sinkler  throws  much  light  upon 
the  symptomatology  of  the  disease,  and  gives  the  details  of  a  classical 
case. 

The  paralysis  may  take  the  form  of  hemiplegia  (Barlow  and  Duchenne 
have  found  cases  of  true  cerebral  hemiplegia,  and  Barlow  has  re- 
ported five  such  cases),  or  it  may  affect  the  voluntary  muscles  of  all  four 
extremities,  and  some  of  those  of  the  trunk ;  but  the  facial  muscles,  as  a 
rule,  escape.  After  a  short  time  there  is  a  return  of  power  in  many  of 
those  at  first  involved,  and  but  a  small  number  of  muscles  (notably  the 
anterior  tibial,  peroneal,  and  others  of  the  leg  and  thigh)  remain  pow- 
erless. 

The  temperature  of  the  paralyzed  muscles  is  much  lowered,  and  there 
is  sometimes  a  difference  of  from  eight  to  twelve  degrees  between  the 
affected  and  normal  sides.  Heine  considers  the  local  reduction  of  tem- 
perature in  old  cases  to  be  from  ten  to  twelve  and  a-half  degrees  Fahren- 
heit. The  bladder  and  bowels  escape  the  paralysis,  and  their  functions 
are  consec|uently  unimpaired. 

Muscular  contractility  is  lost  with  the  commencement  of  the  paralysis, 
and  the  faradic  current  will  rarely  produce  contractions.    Such,  however, 

1  Clinical  Lecture,  Med.  and  Surg.  Reporter,  March  10,  1877. 
^  Am.  Journ.  of  Obstetrics,  May,  1874. 


ANTERO-SPINAL    PARALYSIS    OF    INFANTS.  279 

is  not  the  case  with  the  galvanic,  except  in  extreme  instances,  or  when 
the  case  is  one  of  long  standing.  So  far  there  are  rarely  any  evidences  of 
atrophy  or  contracture  of  the  paralyzed  muscles,  but  it  will  be  found  now 
that  certain  muscles  at  first  affected  begin  to  regain  their  lost  functions, 
while  others  become  atrophied  and  utterly  useless.  Even  the  galvanic 
current  fails  to  stimulate  them  ;  and  at  this  period,  which  may  vary  from 
four  to  five  weeks  to  six  months  from  the  beginning  of  the  disease,  there 
may  be  deformities  and  muscular  contractures,  which  may  result  either 
from  the  weight  of  the  body  upon  the  affected  limb,  or  from  the  anta- 
gonism of  non-paralyzed  muscles  ;  but  Volkmann^  considers  that  this  in- 
capacity of  the  limb  to  support  the  superimposed  load  is  of  much  greater 
importance  as  a  cause  of  deformity  than  the  mere  antagonism  of  the  unaf- 
fected muscles. 

The  foot  is  apt  to  drop  so  that  the  toes  hang  limp  and  flaccid. 
Barlow  alludes  to  the  "  talus  pied  creux,"  a  deformity  described  by  the 
French  writer,  the  instep  being  prominent  and  the  sole  hollowed. 

Such  deformities  may  take  f)lace  as  lateral  curvatures  of  the  spine, 
talipes,  and  other  distortions  which  appear  as  various  muscles  are  par- 
alyzed, or,  if  there  be  shortening  of  the  limb  (which  is  by  no  means  un- 
common), as  a  consequence  of  reduction  in  the  length  and  size  of  bones 
which  have  become  atrophied.  The  deformities  that  may  result  from  the 
disease  under  consideration  are  of  a  j^rimary,  and  of  a  secondary  or  com- 
pensatory nature.  The  primary  forms  are  those  which  are  seen  as  talipes 
of  both  kinds,  and  result  from  loss  of  sustaining  power  of  the  muscles. 
The  compensatory  consist  in  spinal  curvatures,  such  as  lordosis  or  scoliosis.- 
The  skin  is  usually  blue  and  livid,  and  the  temperature  is  much  below 
that  of  the  healthy  limb.  These  deformities  rarely  disappear,  but  con- 
tinue throughout  life,  which  is  in  no  way  shortened  by  the  disease.  The  fol- 
lowing cases  may  be  presented  to  illustrate  the  appearance  and  behavior 
of  the  disease.  The  first  case  is  somewhat  anomalous,  as  there  were  two 
forms  of  paralysis ;  the  primary  attack  being  hemiplegia,  and  the  second- 
ary paraplegia. 

Case  I. — Robert  B.  (a  seventh -month  child)  was  sent  to  me  by  Dr. 
H.  G.  Piffard,  of  this  city.  During  September,  1876,  he  became  fever- 
ish, and,  after  two  days,  duriug  which  he  was  confined  to  bed,  he  had  a 
general  convulsion.  Before  his  fever  he  had  eaten  a  great  quantity  of 
cherries,  and  his  mother  supposed  his  illness  to  be  due  to  this  cause.  The 
mother  stated  that  the  convulsion  lasted  three  and  a  half  hours.  He 
became  paralyzed  two  days  afterwards,  the  right  arm  and  leg  being  af- 
fected; but  two  days  after  this  he  could  use  even  these  limbs.  A  few 
days  subsequently  he  went  out  to  play,  but  came  back  feeling  out  of 
sorts;  and,  after  a  few  hours'  fever,  aaother  spasm  took  place.  Within 
the  next  thirty-six  hours  both  legs  were  paralyzed,  so  that  he  could  not 
stand.  Towards  the  first  of  November  he  regained  some  power,  and  can 
now  stand  when  holding  a  chair. 

1  Sammlung  Klinisher,  Vortrage,  Heft  1,  1870. 

*  Produced  by  attempts  to  restore  disturbed  equilibrium. 


280  DISEASES    OF    THE    SPINAL    CORD. 

Present  Condition. — He  is  a  puny  boy,  about  five  years  old,  and  is  badly 
nourished.  He  has  no  voluntary  power  over  lower  extremities,  but  can 
move  the  arms  perfectly.  The  legs  are  both  very  much  reduced  in  size, 
and  the  muscles  are  flabby  and  atrophied.  The  peronei,  solei,  and  ante- 
rior tibial  muscles  are  reduced  in  size,  and  have  lost  their  electric  con- 
tractility. He  perceives  pinches,  and  changes  of  temperature,  and  the 
"  wire-brush  "  produces  much  pain.  The  skin  is  cold,  mottled,  and  dry, 
and  here  and  there  is  dotted  with  patches  of  scurfy  eruption. 

Case  II. — Annetta  F.,  aged  10  years.  About  three  years  ago  she  be- 
came quite  ill  after  a  sleigh  ride,  and  it  was  supposed  that  she  had 
"  caught  cold."  Her  feverish  symptoms  were  quite  decided,  and  she  was 
slightly  delirious.  After  several  days  she  seemed  to  improve  slightly, 
but  on  awaking  one  morning  it  was  found  that  she  was  paralyzed  and 
unable  to  rise  ;  and  she  complained  of  intense  backache  and  tingling 
of  the  limbs,  which,  however,  were  of  very  short  duration.  About  two 
months  after  this  she  began  to  recover  the  use  of  her  arms,  but  the  legs 
were  more  fully  paralyzed ;  and  it  was  several  months  before  she  began 
to  move  her  toes,  and  finally  made  feeble  movements  of  a  more  extended 
character.  The  muscular  contractions  of  the  flexors  were  performed 
more  easily  than  movements  requiring  extension ;  and,  after  a  time,  she 
attempted  to  walk,  but  at  first  this  act  was  impossible.  During  the  next 
year  she  was  obliged  to  use  crutches,  and  needed  the  assistance  of  her 
nurse.  When  I  saw  her,  there  was  talipes  equinus  varus  of  the  left  foot, 
while  the  right  seemed  to  be  but  little  affected.  Flexion  was  possible,  but 
extension  of  the  leg  or  foot  was  beyond  her  power.  There  was  some  re- 
laxation of  the  ligaments  of  the  knee-joint,  so  that  when  I  made  exten- 
sion I  caused  the  tibia  to  form  an  obtuse  angle  with  the  femur,  so  that 
there  was  some  anterior  curvature.  Her  gait  was  peculiar,  and  she 
swung  the  left  leg,  bringing  it  down  with  a  jerk.  The  skin  covering  the 
left  leg  was  dusky  and  mottled,  and  seemed  in  close  contact  with  the  tis- 
sue beneath  ;  and  the  surface-temperature  was  several  degrees  below  that 
of  the  other  side.     No  rectal  trouble. 

Case  III. — A  gix'l  sent  to  me  by  Dr.  Lockwood,  of  Xorwalk,  had  pre- 
sented, among  other  symptoms,  mitral  disorder,  fever,  general  paralysis, 
residual  paralysis,  paraplegia,  and  paralysis  and  atrophy  of  the  right 
deltoid,  which  cannot  be  made  to  contract  when  subjected  to  either  cur- 
rent.    Right  leg  more  affected  than  the  left. 

Case  IV. — A  girl  10  years  of  age.  At  the  second  year  after  a  fall 
she  became  feverish,  was  delirious,  and  took  to  her  bed.  There  was  gen- 
eral paralysis  of  the  right  leg  and  thigh ;  but  after  three  months  there 
was  improvement,  except  of  the  leg,  which  remained  paralyzed.  There 
are  now  a  pronounced  talipes  varus,  complete  atrophy  of  the  antei'ior 
muscles,  and  utter  loss  of  electro-muscular  contractility.  She  has  used 
various  forms  of  orthopaedic  apparatus  without  relief. 

Case  V. — Frank  X.  C,  4  years  old,  a  stout,  rugged  boy,  enjoyed  good 
health  until  January,  1877,  when  he  contracted  scarlet  fever,  with  albu- 
minuria as  a  result.  From  this  he  recovered,  but  in  August  he  again 
fell  sick  with  what  was  pronounced  to  be  rheumatic  fever.  There  were 
high  temperature,  some  diarrhoea,  which  lasted  for  a  number  of  days, 
painful  joints,  and  loss  of  power  in  both  lower  extremities.  The  power 
returned  in  the  right  leg,  so  that  by  the  middle  of  Ssptember  (three 
Aveeks  from  the  invasion  of  the  fever)  he  had  control  of  that  member. 
The  left  remains  powerless,  and  there  has  been  slow  atrophy.   The  exten- 


ANTEKO-SPINAL    PARALYSIS    OF    INFANTS.  281 

sors  of  the  leg  and  foot  are  now  powerless,  and  there  is  decided  atrophy 
of  these  and  the  posterior  tibial,  abductors  of  the  thigh  and  anterior 
muscles.  The  knee-joints  are  quite  weak,  and  there  are  projections  on 
the  inner  side  of  both  knees.  He  is  knock-kneed,  no  eversion  or  inver- 
sion of  feet,  but  there  is  slight  talipes  of  the  left  foot. 

Case  VI. — Mamie  W.,  6  years  and  1  month  old,  always  was  a  nervous, 
excitable  child.  Has  had  several  convulsions  in  her  life  of  an  epileptic 
character,  without  any  after-effects,  or  apparent  coexisting  disease.  In 
July  last  she  had  whooping-cough.  On  September  4th  she  was  taken 
with  colic,  malaise,  and  convulsions,  during  which  the  body  became  rigid, 
and  she  frothed  at  the  mouth.  These  convulsions  appeared  at  5  P.  M., 
and  lasted  until  midnight.  She  was  unconscious  all  the  time.  At  7  P.  M. 
the  corner  of  the  mouth  became  drawn  up  by  spasms.  She  had  fever 
during  the  following  day  and  for  a  number  of  days.  Did  not  make  any 
attempt  to  move  for  a  number  of  days,  and  for  twelve  days  she  could 
not  speak.  She  was  found  to  be  generally  paralyzed,  and  after  a  short 
time  the  arms  recovered  their  strength,  but  the  legs  began  to  lose  their 
size  and  shape,  and  became  smaller  than  they  were  before.  Her  mental 
condition  is  defective  (five  weeks  after  attack).  And,  though  there  is  no 
impairment  of  bladder  or  rectum,  she  does  not  call  attention  to  her 
wants,  but  defecates  and  urinates  in  her  clothing.  Power  of  upper  ex- 
tremities good.  The  legs  are  cold  and  mottled  ;  there  is  slight  talipes  on 
both  sides ;  and  great  wasting  of  the  flexors  of  the  feet,  especially  of  the 
right.  Faint  contractions  are  excited  by  the  strongest  faradic  currents, 
but  she  can  move  her  toes  very  feebly,  but  not  flex  the  foot.  She  has 
control  over  the  thighs.  Both  feet  are  slightly  everted.  There  is  redness 
of  the  skin  covering  the  right  knee,  but  no  pain ;  no  pain  in  back ;  slight 
impairment  of  sensation,  but  reflex  irritability  not  embarrassed,  as  was 
demonstrated  by  pinching;  pupils  moderately  dilated. 

The  muscles  of  the  leg  are  more  often  affected  than  those  of  any  other 
part.  In  nearly  every  instance  the  tibialis  anticus  is  paralyzed,  and  in  18 
of  the  23  examples  I  have  noticed  this  muscle  was  affected.  The  peroneus 
tertius,  longus;  extensores  longi  digitorum,  proprius  polUcis;  and  the  flex- 
ores  longi  digitorum,  and  longus  pollicis,  are  usually  affected.  The  deltoid 
is  paralyzed  more  rarely,  and  of  the  cases  I  have  enumerated  there  were 
but  two  in  which  this  muscle  was  affected.  The  muscles  of  the  upper 
extremities  are  seldom  involved  in  comparison  with  those  of  the  leg,  and 
those  that  are  usually  paralyzed  are  the  flexors  of  the  hand.  Though 
the  muscles  of  the  trunk  may  be  sometimes  involved  in  the  early  paraly- 
sis, it  is  extremely  rare  that  we  find  any  residual  paralysis  of  any  of 
them.  Barlow  and  others  have  witnessed  repeated  attacks  of  paralysis 
in  the  same  subject  after  apparent  complete  recovery. 

It  is  rare  to  find  either  arthritic  enlargement  or  wasting,  or  bed-sores  in 
uncomplicated  essential  spinal  paralysis  ;  but  this  disease,  which  is  limited 
to  the  anterior  columns,  should  not  be  confounded  with  a  transverse 
myelitis  or  compression  myelitis  that  may  be  found  among  children  which 
are  not  always  clearly  distinguished,  and  give  rise  to  tissue  changes. 

Causes. — The  etiology  of  the  affection  is  anything  but  clear.  Expo- 
sure and  bad  or  insufficient  food  are  supposed  to  account  for  it,  just  as 


282  DISEASES    OF    THE    SPINAL    CORD. 

they  do  for  many  other  diseases  of  the  same  class.  Barlow  alludes  to 
the  fact  that  an  unrecognized  form  of  exposure  arises  from  taking  a  child 
into  a  sleeping-room  with  newly-plastered  walls.  It  is  a  significant  fact 
that  more  of  these  patients  belong  to  the  lower  walks  of  life  than  to  the 
higher,  and  that  the  children  of  the  destitute  poor,  who  come  of  drunken 
parents,  and  are  "knocked  about"  and  half-fed,  are  those  who  are  gene- 
rally the  victims  of  the  disease.  As  to  age,  Siukler  has  found  that  84  of 
108  cases  were  between  the  ages  of  six  months  and  three  years,  and  that 
half  of  this  number  were  males.  Barlow,^  speaking  of  the  infantile  form, 
states  that  he  found  that  there  was  no  great  preponderance  of  the  disease 
in  either  sex,  and  that  of  63  cases  he  had  collected,  33  were  males  and  30 
females.  His  other  statistics  show  that  the  disease  more  commonly  be- 
gins before  the  second  year,  and  that  42  of  the  63  cases  occurred  between 
the  first  and  second  year  of  life.  It  will  thus  be  seen  that  Barlow  sup- 
ports the  other  authors  I  have  mentioned.  Of  53  cases  in  which  the  at- 
tack could  be  fixed  with  accuracy,  27  occurred  in  the  months  of  July  and 
August. 

Duchenne'^  holds  that  two-thirds  of  the  cases  begin  before  the  second 
year,  which  view  I  am  disposed  to  take.  Warm  weather  seems  to  favor 
the  development  of  the  disease,  and  in  nearly  two-thirds  of  Siukler's  cases 
the  disease  began  in  the  months  between  May  and  October,  Cases  have 
been  reported  in  which  the  exanthemata  have  preceded  the  paralysis,  and 
varicella,  measles,  and  scarlatina  may  be  mentioned  among  these  ;  but  it 
is  probable  that  in  the  majority  of  such  cases  sclerosis  not  limited  to  the 
anterior  columns  has  been  the  central  condition. 

Morbid  Anatomy  and  Pathology. — We  are  indebted  to  Char- 
cot' and  Joffroy,  Duchenne,*  Echeverria,^  and  others  for  reports  of 
autopsies  and  microscopical  examinations,  and  as  the  result  of  their  in- 
vestigations the  following  appearances  may  be  looked  for. 

In  the  early  stages  of  the  disease  there  is  probably  a  condition  of  sub- 
acute myelitis,  with  softening  and  destruction  of  nerve-elements,  etc.  This 
is  confined  exclusively  to  the  anterior  horns.  Some  of  the  nei've-cells  of 
this  portion  of  the  cord  are  sometimes  filled  with  granular  pigment  depo- 
sits, while  others  are  disorganized  and  broken  up.  The  nerve-tubes  of  the 
anterior  roots  will  be  found  shrunken,  the  myeline  absent,  but  the  axis 
cylinder  is  nearly  always  intact. 

In  other  cases  of  longer  standing  there  are  evidences  of  atrophy  of  the 
anterior  horns,  perhaps  amyloid  degeneration,  and  sometimes  sclerosis. 
The  nerve-cells  are  found  in  an  atrophic  condition,  or  absent  altogether. 
The  white  matter  of  the  anterior  and  lateral  columns  is  not  rarely  the  seat 
of  such  degeneration,  and  proliferation  of  the  connective  tissue  is  some- 


^  On  Eegressive  Paralysis.     W.  H.  Barlow,  M.  D.,  Manchester,  1878,  p.  4. 
^  De  I'Electrisation  localisee,  3d  ed.,  Paris,  1872,  p.  417. 
*  Archiv.  de  Phys.,  tome  ill.,  1870.  *  Ibid.,  tome  iv.,  1870. 

=  Keflex  Paralysis,  etc.,  p.  29,  New  York,  1866. 


ANTERO-SPINAL    PARALYSIS    OF    INFANTS.  283 

times  found.    In  25  cases,  collected  by  Seguin/  the  constancy  of  the  lesion 
is  very  clearly  shown. 

The  anterior  horns  together  were  affected  in 11  cases. 

The  right  anterior  horn  alone  was  affected  in 1  case. 

The  left  "  "         "  "  " 4  cases. 

Both  affected  in 6     " 

Sclerosis  of  antero-lateral  columns  (chiefly)  and  other  white  matter  13     " 

Tuhercules  and  blood-clots 2     " 

Meningitis  and  meningeal  congestion      2     " 

Damaschino^  and  Roger,  Cornil,^  Clarke,^  Charcot,^  and  Joffroy  have 
added  many  histories  to  those  given  to  the  profession  by  the  early  writers, 
and  it  is  now  well  settled  that  the  anterior  horns  and  lateral  columns  are 
the  seats  of  the  central  lesion. 

Rosenthal®  considers  that  the  primary  cause  is  dilatation  and  thicken- 
ing of  the  vessels,  and  does  not  believe  that  the  morbid  process  begins  by 
degeneration  of  the  nerve-cells.  Notwithstanding  the  appearance  of  well- 
defined  lesions  in  nearly  every  case,  there  are  occasional  examples  of  the 
disease  where  no  central  changes  are  to  be  found.  Ketli^  reports  one  of 
these  in  which  extensive  muscular  alterations  were  visible,  but  not  the 
slightest  indication  of  centi-al  disease.  Elischer^  examined  the  muscles, 
which  were  seen  to  be  the  seat  of  both  fatty  and  colloid  degeneration. 
The  sarcolemma  and  nerves  were  not  altered.  In  the  striated  muscles, 
instead  of  the  single  normal  cell-nucleus,  there  were  seen  three  or  four 
granular  cell-nuclei,  which  seemed  to  be  at  the  same  time  enlarged,  and 
contained  two  or  three,  or  even  more  nucleoli.  The  contractile  material 
was  diminished,  so  that  it  did  not  fill  out  the  sheath,  but  drew  away  from 
it.  This  atrophy  was  so  great  that  at  the  upper  and  under  part  of  the 
spindle-shaped  cell-nucleus  of  the  sheath  there  was  hardly  to  be  found  a 
breadth  of  .002  millimetre  of  cross-striped  contractile  muscular  substance. 
Ketli  thinks  that  these  changes  in  the  muscle  without  central  disease  point 
to  the  peripheral  nature  of  the  afiection,  in  which  opinion  he  has  but  few 
followers.  Lesions  of  peripheral  nerves  have  been  found  by  various  ob- 
servers. Rinecker  ^  reports  an  autopsy,  made  by  Forster,  in  which  these 
nerves  were  found  to  be  thin,  shrunken,  and  greatly  degenerated.  The 
bones  and  muscles  present  appearances  which  are  perhaps  more  interest- 
ing than  those  of  the  cord. 

The  muscular  fibres  are  at  first  found  to  be  reduced  in  size,  and  subse- 
quently the  transverse  striae  gradually  disappear,  while  the  longitu- 
dinal fibres  become  more  marked.  There  is  increase  in  the  connective 
tissue,  and  next  a  fatty  degeneration,  the    oil-globules  taking  the  place 

^  Spinal  Paralysis,  etc.,  pp.  12-13. 

»  Gaz.  Med.  de  Paris,  1871.  '  Ibid.,  1864,  p.  290. 

*  Med.  Chir.  Trans.,  vol.  ii.,  1869,  p.  249. 

6  Op.  cit.  6  Quoted  by  Fox,  op.  cit„  p.  290. 

'  Ibid.  8  Ibid. 

»  Jahrs.  fur  Kinderheilkunde,  1871,  5  Heft  1. 


284 


DISEASES    OF    THE    SPINAL    CORD 

Fig.  38 
A 


o.  Normal  fibre. 
A.  Represents  the  normal  fibres  with  well-marked  transverse  stria}.    B.  The  transverse  strife 
are  not  quite  so  distinct,  but  the  longtitudiual  fibres  are  well  marked. 


Fig.  39. 


Fig.  40. 


<   jr  -%y 

a.  Fat  t.-ells.    b.  Interstitial  fatty  deposits. 

The  stage  of  fatty  degeneration.  A.  The  lon- 
gitudinal fibres  are  only  seen, and  there  is  a  de- 
posit of  round  and  oval  adipose  cells  and  oil-glo- 

ules.    B.  Undulations  of  longitudinal  fibres. 


a.  a.  Fat  molecules. 

The  progressive  fatty  degeneration 
and  the  disappearance  of  longitudinal 
fibres. 


Fig.  41. 


This  illustration  represents  the  final  stages,  in  which  it  will  be  seen  that  the  muscular  fibre  has 
lost  its  identity,  and  at  last  there  is  an  absence  even  of  oil-globules. 

of  the  normal  muscular  tissue,  and  finally  nothing  remains  but  the  con- 
nective tissue  and  fat,  which  latter  disappears,  leaving  the  sarcolemma 
bound  together  by  connective  tissue. 


ANTERO-SPINAL    PARALYSIS     OF    INFANTS.  285 

The  accompanying  cuts,  from  Daclienne,  show  the  changes  that  take 
place. 

The  blood  vessels  running  to  the  atrophied  muscles  are  often  of  smaller 
size  than  they  should  be,  and  sometimes  are  the  subject  of  atheromatous 
degeneration. 

The  bones  also  undergo  atrophic  changes,  becoming  friable  and  thin, 
and  occasionally  the  seat  of  fatty  degeneration.  The  cartilage  covering 
their  articular  extremities  is  roughened,  and  in  some  places  detached. 

Though  some  observers  have  maintained  the  peripheral  origin  of  the 
disease,  the  large  majority  have  adopted  Heine's  original  views  advanced 
in  1840,  and  endorsed  by  Duchenne  in  1855.  The  almost  general  opinion 
that  the  disease  is  of  central  origin  has  been  conclusively  proved,  I  think, 
by  the  large  number  of  autopsies,  the  most  valuable  of  which  have  been 
made  in  late  years. 

Westphal's  views  in  regard  to  the  existence  of  trophic  cells,  which  were 
also  adopted  by  Duchenne,  certainly  receive  decided  confirmation  in  the 
constant  atrophic  processes  which  are  connected  with  degeneration  of  the 
cells  of  the  anterior  horns. 

That  it  is  not  a  disorder  dependent  upon  the  sympathetic  system  has 
been  proved  by  the  utter  absence  of  any  diseased  condition  either  of  the 
ganglia  or  the  nerves. 

Diagnosis. — The  existence  of  febrile  symptoms,  and  the  secondary 
complete  paresis  which  changes  its  character  and  is  finally  confined  to  a 
few  muscles,  the  unimpaired  sensibility,  and  the  rapid  sequence  of 
atrophy  and  deformities  give  this  disease  a  distinct  character  which  does 
not  admit  of  any  mistake  in  diagnosis.  Forms  of  reflex  irritation,  such 
as  ascarides,  adherent  prepuce,  and  like  peripheral  conditions  may  pro- 
duce some  of  the  symptoms,  but  their  non-progressive  character,  and  dis- 
appearance with  the  removal  of  the  cause,  should  make  the  possibility  of 
an  error  very  remote. 

Prognosis. — Much  depends  upon  the  behavior  of  the  muscles  under 
electrical  stimulus.  If  the  least  response  either  to  the  galvanic  or  faradic 
currents  can  be  recognized,  the  chances  are  extremely  good,  and  it  only 
remains  for  the  physician  to  be  patient  and  attentive.  In  regard  to  dura- 
tion and  its  bearing  upon  prognosis,  I  may  state  that  many  cases  have 
been  cured  even  after  deformities  have  taken  place.  Klopsch,^  of  Bres- 
lau,  reports  several  of  these  cases.  In  one  there  was  shortening  of  the 
thigh  and  deformity  of  the  pelvis,  as  well  as  other  serious  troubles.  Much 
of  the  hope  of  cure,  however,  depends  upon  the  care  taken  in  the  treat- 
ment. 

Treatment. — The  most  active  and  useful  agent  in  the  therapeusis  of 
this  disease  is  undoubtedly  electricity,  either  as  galvanism  or  faradism, 
applied  to  the  muscles.  The  treatment  of  the  central  lesion  is  also  of 
importance,  and  it  is  advisable  to  begin  an  eaergetic  course  of  ergot, 
with   the   actual   cautery,   before    the    atrophic    condition    commences. 

1  Ullsburger's  Prize  Essay,  Am.  Journ.  of  Obstet.,  1870-71. 


286  DISEASES    OP    THE    SPINAL    CORD. 

After  this  the  central  disease  is  very  difficult  to  manage.  Heine  recom- 
mended strychnine,  which,  in  young  children,  may  be  given  in  doses  of 
jhth  of  a  grain,  and  afterwards  increased.  Cod-liver  oil  and  sea-air,  good 
food,  and  tonics  are  of  as  much  importance  as  anything  else. 

When  we  come  to  the  treatment  of  the  paralyzed  muscles,  we  may  try 
electricity,  massage,  hypodermic  injections  of  strychnine,  and  the  applica- 
tion of  heat  and  cold.  If  the  faradic  current  be  found  to  be  incapable  of 
producing  contractions  of  the  paralyzed  muscles,  we  must  make  use  of  the 
galvanic.  From  ten  to  thirty'  cells  of  any  good  galvanic  battery  should 
be  employed,  and  the  electrodes  must  be  covered  with  sponge  or  cloth. 
When  the  positive  electrode  is  placed  in  the  groin  (if  the  legs  are 
paralyzed),  and  the  negative  over  the  muscle  or  muscles  paralyzed,  a  con- 
traction may  be  seen  ;  if  such  does  not  take  place,  the  current  may  be 
slowly  intermitted  by  proper  apparatus,  or  by  simply  removing  the  sponge 
from  the  surface  and  reapplying  it  again.  If  the  cuiTcnt  be  too  strong,  or 
if  the  application  be  too  protracted,  we  may  be  disappointed,  for  the  small 
amount  of  electric  irritability  that  exists  may  be  quenched  before  an  ap- 
preciable contraction  is  perceived.  It  is  therefore  better  to  use  a  current 
of  low  tension.  If  we  are  gratified  by  the  appearance  of  a  contraction,  we 
should  produce  two  or  three  more  and  then  stop  for  the  day.  By  increas- 
ing the  muscular  stimulation  little  by  little  each  day,  we  may  finally  create 
powerful  contractions  with  a  minimum  current,  and  after  a  short  time  we 
may  substitute  the  faradic  current.  It  is  of  great  importance  that  muscu- 
lar relaxation  should  be  produced  during  the  use  of  electricity.  I  may 
repeat  what  I  have  already  said,  and  add  that  a  tired  muscle  naturally 
responds  less  perfectly  to  electric  stimulation  than  one  which  is  unim- 
paired. If  massage  is  used,  it  is  well  to  knead  and  rub  each  muscle  every 
day. 

Should  electricity  fail  to  relieve  the  contracted  condition  of  the  limbs, 
which  may  be  present,  we  may  avail  ourselves  of  the  knife.  Tenotomy 
is  often  of  service,  but  it  should  not  be  prematurely  resorted  to,  but  left 
as  a  last  resource  when  all  other  remedies  fail.  Various  methods  for  im- 
proving the  temperature  of  the  paralyzed  limbs  have  been  described  by 
Roth.^ 

In  brief  they  are  the  following : — 1st.  The  position  should  be  attended 
to  in  all  cases;  a  paralyzed  part  should  not  be  permitted  to  hang  down, 
and  to  dangle  about ;  it  should  be  placed  in  a  horizontal  position,  and  the 
coldest  part  should  be  the  highest,  which  assists  the  reflex  of  venous  blood. 

2.  Clothing. — Spun  silk,  a  mixture  of  silk  and  wool,  wool  or  fur  gar- 
ments should  be  worn  next  to  the  skin  ;  it  is  only  in  exceptional  cases 
that  the  hypersesthesia  of  the  cutaneous  nerves  does  not  permit  any  of 
these  materials  to  be  used.   Here  silk  is  placed  next  to  the  skin,  and  wool 

1  It  will  rarely  be  found  necessary  to  use  this  number,  and  it  is  advisable  to  begin 
with  the  weakest  current  that  will  provoke  contractions. 

*  On  Paralysis  in  Infancy,  Childhood,  and  Youth.  London,  1869,  p.  83,  ch.  62, 
quoted  by  Barlow. 


AXTEEO-SPINAL    PARALYSIS    OF    ADULTS. 


287 


or  fur  over  it.  The  paralyzed  part  should  be  well  warmed  before  it  is 
covered  with  bad  conductors  of  heat.  Eoth  recommends  also  exposure 
of  the  leg  to  direct  heat  of  the  fire,  a  screen  with  a  hole  for  protection  of 
the  rest  of  the  body  to  be  provided.  He  also  recommends  the  use  of 
Turkish  baths,  the  application  of  a  bag  filled  with  hot  salt  or  sand,  and 
the  usual  form  of  massage  and  electricity  to  which  I  have  before  alluded. 
Yolkman  speaks  in  glowing  terms  of  the  use  of  Junot's  boot,  which, 
with  the  rubber  muscle  of  Sayre,  and  the  plaster  bandage,  is  a  useful 
form  of  treatment  in  cases  of  long  standing.  The  paralyzed  limb  is  placed 
in  the  boot  and  the  air  exhausted,  so  that  a  determination  of  blood  to  the 
part  shall  be  induced. 


AyTERO-SPi:N"AL  PARALYSIS  OF  ADULTS. 

Synonyms.  —Acute  anterior  spinal  paralysis.  Subacute  general 
anterior  spinal  paralysis  (Duchenne).  Spinal  paralysis  of  adults  (Meyer, 
Charcot,  Gombault).  Myelitis  of  the  anterior  horns 
(Dujardin-Beaumetz,  Seguin).  Acute  spinal  pa- 
ralysis of  adults  (Petitfils).  Anterior  poliomyelitis 
(Erb,  Eisenlohr).  Acute  anterior  poliomyelitis 
(Kussmaul). 

Definition. — A  myelitis  of  the  anterior  horns 
of  the  spinal  cord,  either  symptomatized  by  an 
acute  invasion  attended  by  fever,  and  followed  by 
sudden  paralysis,  or  by  the  gradual  appearance  of 
the  paralysis  which  becomes  complete  and  next  par- 
tially disappears,  leaving  certain  muscles  affected  ; 
unattended  by  loss  of  sensation,  or  vesical  and  rectal 
trouble. 

Symptoms. — I  am  indebted  to  the  little  me- 
moir of  Dr.  E.  C  Seguin  for  assistance  in  the  prepa- 
ration of  this  article,  and  for  the  report  of  a  case 
which  afterwards  fell  under  my  observation  when  I 
followed  him  as  visiting  physician  to  the  Epileptic 
and  Paralytic  Hospital.  Duchenne  ^  first  called 
attention  to  this  form  of  paralysis  as  early  as  1853, 
and  recognized  its  identity  with  infantile  paralysis. 
Li  1863  Charcot^  was  struck  with  the  similitude  be- 
tween the  two  diseases,  and  in  1872-73  and  later 
years  Gombault,^  Dujardin-Beaumetz,*  Petitfils,^ 
and  Bernhardt  ^  have  presented  cases,  and  decided  the  fact  that  infantile 


Antero-spinal  Paralysi? 
(Seguin). 


1  De  1' Electrisation  localis^e,  Paris,  1872,  p.  437  et  seq. 

^  Papers  of  Petitfils. 

^  Archiv.  de  Physiol,  norm,  et  path.,  1873,  pp.  80-87. 

*De  la  myelite  aigiie,  Paris,   1872. 

^  Consideration  sur  I'atrophie  aigiie  des  cellules  motrices,  Paris,  1873. 

®  Arch,  fiir  Psvch.  und  Xervenkrank,  1874. 


288        .  DISEASES    OF    THE    SPINAL    CORD. 

paralysis  had  an  analogue  in  adult  life.  Gombault  brought  forward  the 
first  case  Avith  an  autopsy  confirming  the  theory  enunciated  by  Duchenne, 
and  in  this  country  the  admirable  little  works  of  Seguin  epitomize  all  that 
has  already  been  brought  forward.  The  first  case  seen  by  Seguin^  has 
since  fallen  under  my  observation,  and  from  his  published  notes  I  copy 
her  history. 

Female,  unmarried,  aged  twenty  years.  Admitted  to  the  Epileptic  and 
Paralytic  Hospital,  Blackwell's  Island,  service  of  Dr.  E.  C.  Seguin,  No- 
vember, 1871.  Patient  presents  a  paralyzed  and  extremely  atrophied  left 
leg,  and  gives  the  following  imperfect  history  :  The  trouble  began  nine 
months  ago,  suddenly  during  sleep,  with  painful  conti'actions ;  she  then 
gradually  (?)  lost  power  in  the  left  leg  ;  no  other  limb  affected.  The 
patient  cannot  state  how  long  a  time  elapsed  between  the  first  symptom 
and  the  discovery  of  palsy.  She  adds  that,  on  the  day  before  the  attack, 
her  left  leg  felt  quite  cold  and  a  little  numb  ;  and  that  her  menses  were 
suppressed.     No  cause  is  apparent — no  hereditary  influence,  no  injury. 

Examination:  Left  foot  is  drawn  up  in  moderate pe.s  eqidnus,  with  in- 
ward inclination.  No  voluntary  movements  below  the  knee.  The  pa- 
tient's answers  to  the  sesthesiometer  test  are  unreliable  ;  sensibility  to 
painful  impressions  is  somewhat  impaired,  that  to  temperature  preserved  ; 
tickling  is  felt  equally  on  both  feet.  Pressure  shows  tenderness  over  the 
lumbar  vertebrje  ;  no  spontaneous  pain.  The  right  calf  measures  26.9  c. 
in  circumference,  the  left  23.7  c.  There  is  absolute  loss  of  electro-mus- 
lar  contractility  in  all  the  muscles  of  left  leg.  The  left  leg  is  very  cold, 
and  its  circulation  feeble.  I  frequently  called  the  attention  of  the  resident 
staff"  and  of  friends  to  this  remarkable  case  as  one  of  the  same  kind  as 
that  which,  occurring  in  the  early  years  of  life,  we  call  infantile  spinal 
palsy. 

The  subsequent  history  need  not  be  reported.  No  treatment  did  any 
good ;  the  girl  remained  in  the  hospital  without  any  acute  symptoms,  and 
went  away  October  3,  1873,  carrying  this  wasted  left  leg.  She  was  em- 
ployed as  a  help  in  the  wards  of  the  Convalescent  Hospital  on  Hart's 
Island,  and  was  there  much  exposed  to  cold. 

The  second  attack,  of  wdiich  patient  gives  a  good  account,  came  on  late 
in  December,  1873.  Had  pains  "  like  rheumatism  "  in  right  leg  ;  there 
was  a  feeling  of  pins  and  needles  in  the  limb,  this  numbness  extending 
above  the  knee.  She  is  positive  that  on  the  fourth  day  the  right  leg  was 
completely  paralyzed.  No  symptoms  in  left  leg.  No  bedsore,  and  no 
affection  of  bladder  or  rectum.  Re-admitted  to  the  Epileptic  and  Para- 
lytic Hospital,  March  3,  1874,  with  atrophy  and  paLsy  of  both  legs  ;  no 
acute  symptoms. 

During  the  spring  and  summer  this  patient  rather  gradually  lost 
strength  in  the  thighs,  in  the  right  most.  She  also  exhibited  a  variety  of 
interesting  visceral  disturbances,  consisting  of  amenorrhoea,  lasting  two 
or  three  months ;  the  menses  then  appearing  with  much  pain,  the  blood 
abundant  and  in  clots ;  there  were  also  pains  in  the  back  and  lower  ab- 
domen. On  many  days  in  this  period  the  urine  had  to  ba  drawn  oflT  with 
the  catheter,  and  it  often  was  bloody,  exhibiting  a  heavy  mucous  deposit, 
and  containing  albumen.  The  microscope  showed  only  leucocytes  and  a 
variety  of  epithelial  cells — there  being  probably  both  pyelitis  and  cystitis . 

*  Spinal  Paralysis,  N.  York,  1874,  and  Anterior  Myelitis,  1877. 


ANTERO-SPINAL    PARALYSIS    OF    ADULTS.  289 

Since  the  middle  of  September  has  not  required  the  catheter,  and,  with 
exception  of  palsy,  has  been  better. 

Re-examined  October  25,  1874.  Patient,  when  she  first  came  in  this 
year,  walked  ill  with  a  crutch  and  stick ;  is  now  able  to  walk  with  two 
sticks  (result  of  education).  Cannot  stand  or  walk  without  help.  The 
patient  is  a  stout  and  healthy  girl,  exhibiting  nothing  abnormal  above 
the  hips.  Both  lower  extremities  are  extensively  palsied  and  much* 
wasted.  The  left  leg  (first  attacked  in  1871)  shows  no  voluntary  move- 
ment below  the  knee,  with  exception  of  slight  separation  of  the  toes.  As 
the  patient  lies  on  the  bed  she  is  able  to  raise  the  extended  limb  as  a 
whole ;  but  the  strength  at  knee-joint  is  small.  The  thigh  is  thin  and 
flabby ;  the  leg  is  the  seat  of  extreme  atrophy,  and  looks  just  like  the 
same  part  in  cases  of  infantile  spinal  palsy,  there  being  apparently  only 
connective  tissue  and  fat  around  the  bones,  the  skin  being  bluish  and 
very  cold  to  the  touch.  The  right  lower  extremity  (paralyzed  in  1873) 
is  in  a  very  similar  though  less  extreme  state.  All  voluntary  move- 
ments are  possible  with  the  foot,  though  they  are  feebly  performed.  The 
limb,  as  a  whole,  cannot  be  raised  from  the  bed,  and  flexion  at  knee-joint 
is  weak.  The  quadriceps  extensor  femoris  is  wholly  paralyzed  ;  the 
flexors  of  the  thigh  upon  the  body  act  feebly  ;  the  adductors  fairly. 
Both  feet  lie  extended  and  adducted  ;  toes  flexed.  The  right  leg  is, 
like  the  left,  extremely  wasted,  bluish  and  quite  cold.  Sensibility  to 
contact,  pain,  and  temperature  are  preserved  in  both  limbs.  Tickling 
is  felt,  but  produces  no  reflex  movement  in  the  palsied  parts.  The 
electro-muscular  reaction  of  the-  atrophied  muscles  of  both  limbs  is  lost 
(both  currents).  At  present,  urine  is  passed  normally.  The  patient's 
arms,  shoulders,  and  chest  are  large  and  rounded,  standing  in  remarkable 
contrast  to  the  dwindled  legs.  There  have  been  no  bedsores  and  no 
spinal  epilepsy. 

Circumference  of  right  thigh  (lower  third) 31.5  c. 

left        "  "  "       30.5 

"  right  calf 24.0 

"  left       " 21.5 

''  forearms 25.0 

On  a  healthy  girl  (non-palsied)  of  same  proportions  as  the  patient,  the 
following  measurements  are  obtained  : — 

Circumference  of  right  calf 35.0  c. 

"    .  left       " 34.5 

"  forearms '. 24.0 

The  patient  having  been  in  bed  some  time,  well  covered  up,  has  a 
thermometer  held  between  the  great  and  second  toes  of  each  foot  for 
three  minutes,  with  results: — Right  side,  84.25°  Fahr.  ;  left  side,  86° 
Fahr. 

In  March,  1876,  the  patient  came  under  my  charge,  when  I  found  that 
her  condition  was  somewhat  aggravated.  She  manages  to  go  about  with 
the  aid  of  crutches,  but  has  utter  loss  of  power  below  the  knees.  The 
tactile  sensibility  is  much  lowered,  and  tickling  can  be  borne  without  any 
reflex  movement  being  produced,  and  she  has  lost  control  to  a  great  ex- 
tent over  the  bladder  and  rectum. 
19 


290  DISEASES    OF    THE    SPINAL    CORD. 

Another  case  reported  by  Lincoln  is  well  worth  presenting,  as  illustra- 
tive of  this  form  of  disease  beginning  without  fever. 

A  tall,  stout  man/  49  years  of  age  and  of  previous  good  health,  noticed 
one  morning,  without  any  previous  symptoms,  a  feeling  in  his  legs  as  if 
they  had  fallen  asleep.  The  feeling  came  on  again  and  again  through 
the  day,  and  he  began  to  be  a  little  weak  in  the  legs.  In  the  afternoon, 
when  trying  to  step  upon  the  platform  of  a  street  car,  he  failed,  and  had 
to  be  helped  in.  On  arriving  home,  he  was  able  (with  assistance)  to  walk 
up  stairs  to  his  bedroom,  and  went  to  bed,  where  he  remained. 

When  seen  by  Dr.  L.,  two  days  later,  he  felt  well,  no  giddiness,  mus- 
cles of  face  and  eyeballs  under  perfect  control,  pupils  normal  in  size  and 
contracted  well,  speech  natural,  vision  and  hearing  without  defect.  The 
bladder  and  rectum  performed  their  functions  normally.  The  senses  of 
touch,  pain,  and  temperature  were  normal  in  the  hands,  and  nearly  so  in 
the  feet.  Reflex  contractions  could  scarcely  be  obtained  from  the  soles. 
There  were  no  abnormal  sensations.  Pulse,  80  ;  temperature,  98°.  No 
albumen  in  the  urine. 

The  muscles  of  the  neck  and  limbs,  except  below  the  knees,  were  gene- 
rally in  a  condition  of  semi-paralysis.  He  lay  on  his  back  almost  help- 
less ;  could  not  raise  his  head  from  the  pillow  without  some  help,  and 
could  not  raise  his  knees  from  the  bed  by  flexing  the  thighs.  The  grasp 
of  his  hand  was  very  feeble  indeed.  There  was  no  paralysis  of  any  mus- 
cle. Below  the  knees  he  seemed  to  have  more  strength.  The  weakness 
was  much  more  marked  on  the  left  than  on  the  right. 

Treatment  consisted  at  first  in  nux  vomica  and  cinchona,  and  subse- 
quently tincture  of  iron  with  strychnia,  and  Horsford's  acid  phosphates  of 
lime  and  magnesia.  On  the  fifth  day  of  the  attack,  treatment  by  the 
induced  electric  current  was  begun,  when  it  was  found  that  some  at  least 
of  the  muscles  had  lost  part  of  their  susceptibility  to  this  stimulus.  The 
loss  went  on  increasing  until  the  twenty-first  day,  when  the  galvanic  cur- 
rent was  substituted,  a  descending  current  being  applied  to  the  spine,  and 
interrupted  currents  to  the  muscles,  three  times  a  week;  the  faradic  cur- 
rent was  also  continued  for  a  few  weeks. 

The  hot-air  bath  to  profuse  perspiration  was  used  just  before  the  appli- 
cation of  the  currents,  together  with  regulated  gymnastic  exercises.  The 
paralysis  of  the  muscles  was  gradually  relieved  under  this  treatment  to  a 
very  considerable  degree.  The  patient's  improvement  was  very  gradual, 
and  it  was  six  months  before  he  was  able  to  ride  out.  He  finally  was  en- 
abled to  attend  to  his  business  pretty  much  as  before  the  attack. 

Other  cases  begin  much  more  slowly,  and  several  of  this  kind  are  re- 
ported by  Duchenne,  but  the  origin  of  the  disease  is  nearly  always  sud- 
den. There  may  be  pain  or  dyssesthetic  symptoms,  or  no  warning  at  all, 
the  patient  awaking  in  the  morning  and  finding  himself  paralyzed,  as 
was  the  cass  with  Seguin's  patient.  Like  the  infantile  form,  there  may 
be  an  acute  attack  of  fever,  which  may  last  for  several  days,  during 
which  there  is  usually  delirium  or  rigors.  The  paralysis  appears  during 
this  time,  and  may  be  general,  so  that  the  upper  and  lower  limbs  are  af- 
fected and  the  loss  of  power  is  complete.     The  functions  of  the  bladder 

1  Boston  Medical  and  Surgical  Journal,  March  25,  1876. 


ANTER0-8PINAL    PARALYSIS    OF    ADULTS.  291 

and  sphincter  ani  are  always  normally  performed  until  other  parts  of  the 
cord  are  affected,  and  there  is  neither  incontinence  of  urine  nor  involun- 
tary evacuations.  At  the  end  of  a  few  weeks  there  is  a  commencing  im- 
provement, some  of  the  muscles  regaining  their  lost  power  and  contracting 
quickly  under  electric  stimulus,  while  atrophy  of  those  already  paralyzed 
begins  to  take  place.  The  skin  over  the  paralyzed  limb  is  quite  cold  and 
blue,  and  there  is  diminution  of  temperature  and  faradic  excitability, 
while  ultimately  it  is  impossible  to  provoke  any  response,  and  the  limbs 
become  deformed  and  twisted.  Atrophy  of  deeper  parts  follow,  and  the 
bones  become  reduced  in  size,  while  the  articular  ends  appear  large  in 
contrast  with  the  attenuated  size  of  their  shafts.  Sensibility  is  rarely 
disordered,  though  exceptional  cases  of  anaesthesia  or  hypersesthesia  are 
met  with,  but  after  the  inflammation  has  involved  the  posterior  columns 
the  phenomena  of  general  myelitis  are  presented.  Dyssesthesise  are  com- 
mon, and  the  patients  complain  of  subjective  cold,  various  pains,  and  the 
waist-constricting  band.  The  muscles  of  the  face,  neck,  chest,  and  abdo- 
men are  rarely  afiected,  but  the  extremities  remain  deprived  of  pain  after 
there  has  been  a  considerable  retrocession  of  the  original  complete  paral- 
ysis. The  atrophy  is  rapid,  and  differs  from  that  of  progressive  muscu- 
lar atrophy  in  the  tact  that  whole  groups  are  affected  at  a  time,  while  the 
peculiarity  of  progressive  muscular  atrophy  is  that  muscles  are  irregu- 
larly affected.     There  are  never  bedsores. 

The  disease  may  be  so  rapid  in  its  development  as  to  suggest  the  mal- 
ady known  as  acute  ascending  paralysis,  and  it  is  probable  in  such  case 
that  the  extension  of  the  disease  proper  is  not  always  confined  alone  to 
the  anterior  columns. 

Erb  ^  alludes  to  a  light  variety  of  spinal  paralysis,  which  has  been  de- 
scribed by  Kennedy,  Fry,  and  others.  To  this  variety  has  been  given 
the  name  "  temporary  spinal  paralysis."  The  paralysis  is  characterized 
by  its  brief  duration,  and  may  involve  a  limited  group  of  muscles  or  seve- 
ral groups.  It  would  seem,  therefore,  that  there  are  two  varieties :  the 
temporary  and  permanent ;  but  Seguin  and  others  have  made  the  classifi- 
cation acute,  subacute,  and  chronic,  which  is  based  rather  upon  the  variety 
of  myelitis  than  the  paralysis.  Ducheune  applies  the  term  sub-acute 
to  the  former,  which  begins  without  fever,  attacks  the  lower  extremi- 
ties first,  and,  extending  upwards,  involves  the  muscles  of  respiration  and 
deglutition. 

Causes. — The  same  unsatisfactory  history  of  exposure,  fatigue,  and 
peripheral  irritation  is  connected  with  the  history  of  this  as  well  as  other 
spinal  diseases.  In  four  of  Seguin's  cases  surface  exposure  to  cold  is  said 
to  have  produced  the  attack,  and  in  three  other  cases,  "  refrigeration  "  is 
named,  while  in  others  dysentery,  measles,  and  other  acute  diseases  were 
at  the  origin  of  the  trouble. 

As  regards  age  and  sex,  I  can  do  no  better  than  refer  to  the  tables  of 
Seguin.     All  of  the  patients  whose  histories  he  collected  were  of  middle 

^  Archiv.  fur  Psychiatrie,  Band  v.,  Heft  3. 


292  DISEASES    OF    THE    SPINAL    CORD. 

age.  "  The  greatest  age  at  the  time  of  seizure  was  62  years,  the  least  18 
years."  Among  17  cases  reported  by  various  observers,  there  were  13 
men  and  4  women. 

Morbid  Anatomy  and  Pathology.— But  very  little  light  has 
been  thrown  upon  the  morbid  anatomy  of  the  cord,  which  accounts  for 
this  form  of  paralysis.     Chalret'  and  Gombault'  have  reported  two  cases. 

The  appearances  found  may  be  briefly  enumerated  as  these :  The  hori- 
zontal fibres  which  pass  from  the  anterior  horns  to  form  the  anterior 
spinal  nerve-roots  were  diminished  in  size,  and  the  large  ganglion -cells  of 
the  anterior  roots  were  atrophied,  having  undergone  yellow  pigmentation. 
Some  of  the  nerve-cells  which  had  not  undergone  this  form  of  degenera- 
tion, were  also  reduced  in  size.  This  information  is  very  meagre, 
though  these  two  cases  illustrate  the  pathological  anatomy  of  the  dis- 
ease. Charcot  and  the  majority  of  observers  believe  that  the  situation 
of  the  lesion  is  always  in  the  anterior  horns.  The  only  matter  of  dis- 
pute seems  to  be  whether  or  not  there  is  primary  degeneration  of  the 
cells,  or  an  acute  interstitial  myelitis  and  .secondary  injury  of  the  nerve- 
cells.     This  latter  view  is  held  by  Erb,-'  and,  I  think,  is  being  generally 

adopted.  -u-  i   • 

The  muscles  were  found  to  be  in  a  state  of  fatty  granulation,  which  is 
the  case  in  the  infantile  variety.  In  some  respects  the  disease  resembles 
progressive  muscular  atrophy  and  bulbar  paralysis,  the  lesion  being  atro- 
phy of  the  motor  and  trophic  cells,  but  it  is  probable  that  the  trophic 
cells  are  primarily  affected  in  these  latter  diseases. 

Diagnosis.— Antero-spinal  paralysis  is  likely  to  be  sometimes  mis- 
taken for  progressive  muscular  atrophy.  If  we  bear  in  mind  its  sudden 
or  almost  sudden  and  complete  origin  ;  the  absence  as  a  rule  of  fibrillary 
tremors  (only  two  cases  which  presented  these  symptoms  having  been  re- 
ported) ;  that  the  paralysis  precedes  the  atrophy,  and  retrocedes  after  the 
first  general  attack  ;  that  electric  irritability  is  primarily  lost ;  and  that 
the  atrophy  involves  the  muscles  of  one  or  more  (usually  two)  extremi- 
ties, there  need  be  no  error  made  in  diagnosis.  Anaesthesia,  incontinence, 
and  paralysis  of  the  sphincter  ani  prevent  it  from  being  confounded  with 
general  myelitis,  these  symptoms  belonging  to  the  latter  in  addition  to  the 
loss  of  power  and  atrophy.  Spinal  congestion  may  sometimes  give  rise  to 
some  of  the  symptoms,  and  Cartwig*  presented  a  case  which  he  called 
"  intermittent,"  somewhat  resembling  the  lighter  form  of  true  antero-spinal 
paralysis. 

A  sugar-baker,  aged  23,  who  was  exposed  to  great  heat  and  sudden 
changes  of  temperature  while  very  lightly  clothed,  had  suffered  m  his 
eighteenth  year  for  four  or  five  weeks  from  an  attack  of  tertian  ague, 
from  which  he  recovered-  One  day  lie  perceived  a  numbness  in  his  legs, 
which  rapidly  attacked  his  arms  also,  and  finally  led  to  complete  para- 

1  These  de  Paris,  1872. 

2  Archives  de  Physiol.,  norm,  et  path.,  tome  v.,  1873.  *  Op.  cit. 
*  Centralblatt  f.  d.  med.  wis.,  June  15,  1870. 


ANTERO-SPINAL    PARALYSIS     OF    ADULTS.  293 

lysis  of  the  muscles  of  the  neck.  Speech,  deglutition,  and  respiration 
were  somewhat  impeded ;  the  muscles  of  the  eye  were  unaffected,  as  were 
also  the  alvine  and  urinary  excretions,  and  sensation.  After  twenty-four 
hours  there  was  a  remission  of  the  symptoms ;  first  the  neck  began  to 
become  movable,  then  the  fingers,  arms,  body,  and  finally  the  legs.  All 
this  took  place  in  half  an  hour,  and  was  followed  by  an  increase  of  per- 
spiration. During  the  next  twenty-four  hours  the  patient  remained  free 
from  paralysis,  but  was  dull ;  after  which,  the  above-described  symptoms 
returned.  The  brain  was  always  free  ;  the  cervical  portion,  especially 
the  upper,  was  not  always  equally  affected ;  the  movements  of  the  neck 
were  often  free  ;  and  difficulty  in  deglutition  and  respiration,  inequality 
of  the  pupils,  and  myosis,  were  frequently  present.  The  phrenic  nerve 
was  always  unaffected.  When  there  was  not  complete  paralysis,  the 
affected  limbs  were  generally  stiff,  and  there  was  contraction  of  the  pre- 
dominating groups  of  muscles  ;  when  complete  paralysis  was  present,  the 
muscles  were  soft  and  flabby.  Electro-muscular  irritability  was  almost 
conipletely  absent  during  the  paralysis,  and  the  violence  of  the  muscles 
varied.  Under  the  use  of  quinine,  the  patient's  condition  was  on  several 
occasions  quickly  improved,  but  he  was  not  cured.  He  was  under  obser- 
vation for  more  than  six  months.  The  author  believes  that  the  case  was 
one  of  masked  intermittent,  and  that  the  phenomena  were  due  to  hyper^e- 
mia  of  the  cord  and  occasional  increase  of  serous  exudation. 

In  spinal  congestion  there  are  no  deformities,  no  atrophy,  and  nearly 
always  vesical  trouble  and  constipation. 

Acute  ascending  paralysis  resembles  very  closely  certain  forms  of  the 
disease  under  consideration.  In  one  remarkable  case  reported  by  Des- 
j^rine,^  no  morbid  appearances  were  found  after  death.  A  man  entered 
the  hospital  suffering  from  undefined  pain  in  the  lower  limbs,  and 
two  days  after  became  paraplegic  without  any  loss  of  sensibility.  The 
paralysis  rapidly  succeeded,  and,  after  four  days,  he  died ;  no  trace  of 
disease  after  paralysis  of  the  respiratory  muscles  could  be  found  except 
dilated  vessels. 

Seguin  considers  that  this  involvement  of  the  respiratory  muscles  is  a 
diagnostic  sign. 

Prognosis. — Antero-spinal  paralysis  is  not  a  disease  which  is  rapidly 
fatal,  and  many  cases  recover  within  a  short  time  after  the  beginning  of 
the  attack.  I  am  not  disposed  to  think  that  the  lesion  is  an  ascending 
one;^  but  rather  that,  if  it  progresses  at  all,  it  involves  the  posterior  and 
laterial  parts  of  the  cord  in  the  majority  of  cases,  and  does  not  sjijread 
longitudinally.  This  ia  probably  the  condition  of  affairs  in  the  case  of 
S.  W.  Should  the  paralyzed  muscles  become  atrophied  to  such  an  extent 
that  deformities  result,  I  think  that  there  is  very  little  hope  for  the 
patient.  If,  however,  the  muscles  can  be  made  to  respond  to  the  galvanic 
current,  we  should  never  be  discouraged. 

Of  the  cases  reported  by  Duchenne,  Meyer,  Bernhardt,  Seguin  and 
others,  I  find  that  of  16  cases  there  were  but  2  deaths.  In  one  observation 
there  was  improvement  in  six  months,  in  another  in  four,  and  in  others  two, 

^  Archives  de  Physiol.,  etc.,  June,  1876. 


294  DISEASES    OP    THE    SPINAL    CORD. 

three,  eleven,  and  twelve.     In  two  cases  the  patients  were  cured,  and  in 
several  there  was  progressive  unfavorable  advancement. 

Treatment.— In  electricity  we  possess  a  remedy  of  the  greatest 
value.  I  have  already  called  attention  to  its  use  in  the  infantile  form  of 
the  disease,  so  there  is  no  need  for  going  into  details.  It  is  well  to  use 
both  the  galvanic  and  faradic  currents,  and  in  the  acute  form  of  the  trou- 
ble we  should  begin  with  counter-irritation  of  the  spine  as  early  as  possi- 
ble, and  for  this  purpose  may  employ  blisters  or  the  actual  cautery. 

Ergot  and  belladonna  in  rather  full  doses  should  be  employed  in  con- 
junctfon  therewith.  Seguin  recommends  leeching  and  dry  cups,  which 
are  both  excellent. 

Should  the  pain  be  severe,  we  may  use  morphine  by  means  of  the  hy- 
podermic syringe ;  or  spinal  galvanization.  The  after  treatment  should 
be  with  the  galvanic  current. 

The  use  of  warm  applications,  such  as  have  been  spoken  of  as  of  benefit 
in  the  infantile  variety,  are  worthy  of  trial. 


PROGRESSIVE    MUSCULAR    ATROPHY.  295 


CHAPTER    X. 

DISEASES  OF  THE  SPHSTAL  CORD  (Continued). 
PROGRESSIVE  MUSCULAR  ATROPHY. 

Synonyms. — Wasting  palsy ;  CruTeilhier's  paralysis  ;  Progressive 
muskelatropliie  ;  Progressive  muskellahmung. 

Definition. — This  is  an  essentially  progressive  atrophy  of  certain 
groups  of  muscles.  It  is  not  preceded  by  any  paralysis,  but  followed  by 
loss  of  power,  and  terminates  usually  by  involvement  of  the  respiratory 
nerve-centres. 

Cooke,^  in  1795,  directed  attention  to  a  condition  he  called  "  anomalous 
hemiplegia"  which  was  clearly  progressive  muscular  atrophy,  and  his 
was  probably  the  first  recorded  case.  Bell,^  Abercrombie,^  and  Darwell* 
each  published  cases  which  were  undoubtedly  of  this  kind;  and, in  1836, 
Mayo ^  related  two  cases.  It  was  not,  however,  till  1849,  when  Duchenne 
de  Boulogne  ^  presented  a  memoir  to  the  Institute  of  France,  entitled 
"  Atrophie  musculaire  area  transformation  graisseuse,"  that  the  present 
disease  was  recognized.  In  1853,  Cruveilhier^  described  some  cases  in 
which  the  atrophy  was  general,  all  the  voluntary  muscles  being  affected. 
In  1850-1861,  Aran,'  Duchenne,'^  and  Eisenmann^'^  brought  forward  ad- 
ditional facts,  and  the  latter  agreed  with  Cruveilhier  that  the  "  nerves 
or  nervous  centres  are  at  fault  anterior  to  the  muscles,  and  that  the 
atrophy  of  the  latter  is  a  secondary  process."  Since  that  time  we  are  in- 
debted to  Roberts"  and  Friedreich^-  for  most  clear  and  instructive  de- 
scriptions. 

Symptoms. — The  appearance  and  progress  of  the  disease  are  most 
gradual.  The  affected  individual  may  first  notice  a  slight  weak- 
ness in  one  of  the  upper  extremities.  Perhaps  the  first  indicattion  of 
trouble    which    suggests   to    the    patient    the    commencement    of   the 

1  Cooke  on  Palsv,  p.  31,1822. 

^  The  Nervous  System  of  the  Human  Body,  London,  1830. 

3  On  the  Brain  and  Spinal  Cord,  p.  419,  Edin.,  1828. 

*  Lond.  Med.  Gaz.,  vol.  vii-,  p.  201. 

3  Outlines  of  Human  Pathology,  p.  117,  London,  1836. 

6  Memoires  de  I'Acad.  des  Sciences,  1849- 

^  Archives  Gen.  de  M^d.,  May,  1853. 

8  Ibid.,  Sept.,  1850. 

'  De  I'Electrisation  localisfee,  Paris,  1855-61. 

"  Canstatt's  Jahresbericht,  1859. 

11  An  Essay  on  AVasting  Palsy,  London,  1858. 

12  Ueber  progressive  muskelatrophie,  etc.,  Berlin,  1873. 


296 


DISEASES    OF    THE    SPINAL    CORD, 


(Fig.  43). 


disease,  is  when  the  act  of  writing  is  attempted.  According  to  Roberts, 
the  disease  begins,  in  two-thirds  of  the  cases,  in  the  upper  extremities, 
and  the  muscles  of  the  hands  are  the  first  to  suffer  loss  of  function.  Very 
often  several  muscles  are  affected  together,  and  they  soon  become  agitated 
by  what  are  known  2l^  fibrillary  contractions,  or,  as  they  have  been  called, 
vermicular  contractions,  which  in  their  nature  are  probably  a  divided  re- 
flex excitation.  The  subcutaneous  contraction  of  muscular  filaments  sug- 
gests the  appearance  of  worms  crawliug  beneath  the  skin,  and  there  is 
sometimes  a  species  of  muscular  shivering.  These  fibrillary  contractions 
may  be  excited  by  sharply  striking  the  muscles  with  a  ruler  on  the  hand, 
and  they  sometimes  follow  the  passage  of  the  galvanic  current  through 
a  nerve-trunk.  As  I  have  said,  the  hand  may  be  affected  first,  and 
there  may  be  extensive  wasting  here  before  other  parts  are  attacked.  The 
muscles  of  the  palm  of  the  hands,  when  atrophied,  give  to  that  member 
a  most  unsightly  appearance.  The  bones  stand  out  in  strong  relief,  and 
the  thenar  and  hypothenar  eminences  are  flattened,  and  the  flexor  ten- 
dons are  prominent,  and  increase  the  deformity.  With  this  there  is  con- 
traction of  the  flexors,  and  the  hand  resembles  more  the  claw  (Fig.  43) 

of  an  animal  than  anything  else,  so  that  it 
has  been  called  "main  en  griffe."  The 
back  of  the  hand  also  presents  a  most  skele- 
ton-like aspect,  the  extensors,  the  interossei 
muscles,  and  sometimes  the  adductors  of  the 
thumb  having  been  reduced  in  size.  The 
forearm  and  arm  are  next  to  follow,  and 
rapidly  lose  their  normal  conformation.  The 
deltoid  and  serrati  muscles  may  be  involved, 
while  those  of  the  arm  proper  may  occasion- 
ally be  passed  over.  The  head  of  the  hu- 
merus and  angle  of  the  scapula  are  quite  dis- 
tinct, and  this  bone  may  be  drawn  out  of 
place  by  the  healthy  muscles,  this  being  the 
rule  when  the  serratus  magnus  is  the  seat  of 
atrophy.  The  angle  of  the  scapula  is  drawn 
upwards  and  inwards,  and  stands  out  from 
the  trunk.  It  is  rare  to  find  symmetrical  atrophy,  and  in  the  majority 
of  cases  I  have  seen  there  has  been  a  great  difference  in  the  invasion  of 
muscles  on  the  two  sides.  The  right  upper  extremity  appears  to  be  the 
favorite  seat  of  the  atrophy,  while  the  lower  extremities  are  quite  rarely 
affected,  and  in  the  proportion  of  1  to  12  to  the  upper  extremities.  The 
muscles  of  the  face  and  head  are  sometimes  the  seat  of  atrophy,  but  this 
is  unusual,  though  muscles  may  occasionally  be  so  extremely  wasted  that 
there  is  no  appearance  of  intelligence  whatever.  The  eyes,  of  course, 
being  unaffected,  are  the  only  agents  of  expression.  There  may  be  atro- 
phy of  the  tongue  and  buccal  muscles,  with  disturbances  of  speech  and 
drooling  of  saliva,  and  in  such  cases  death  usually  follows  in  a  very  short 
time.     Sometimes  the  muscles  of  the  neck  do  not  escape  the  extension  of 


"  main  en  griffe'  (Duetienne.) 


PROGRESSIYE    MUSCULAR    ATROPHY.  297 

the  disease,  and  the  chin  falls  forwards  and  downwards.  The  last  mus- 
cles involved  are  generally  those  concerned  in  respiration  ;  and  not  only 
are  the  intercostals  the  subjects  of  such  a  change,  but  the  diaphragm  is 
finally  paralyzed,  so  that  the  action  of  the  lungs  is  interfered  with,  and 
ultimately  the  patient  is  literally  asphyxiated.  Subsequent  to  atrophy, 
a  loss  of  power  takes  place.  The  affected  muscles  preserve  for  a  long 
time  their  electric  contractility ;  but  this  is  finally  lost  as  they  decrease  in 
size,  and  loss  of  power  increases  till  finally  the  patient  becomes  helpless. 
Duchenne  is  of  the  opinion  that  the  loss  of  voluntary  muscular  contractil- 
ity is  rather  the  contequence  of  atrophy  or  textural  alteration  than  of 
paralysis,  i.  e.,  loss  of  motor  innervation  ("C'est-a-dire  du  defaut  d'action 
nerveuse  motrice").  Tactile  sensibility  is,  however,  rarely  blunted.  One 
of  the  earliest  symptoms  of  progressive  muscular  atrophy  is  the  presence 
of  dull  pains  in  the  affected  limbs,  and  this  has  led  very  frequently  to  a 
mistake  in  diagnosis,  the  condition  being  often  considered  rheumatic.  In 
one  case  sent  to  me  by  Dr.  E.  G.  Loring,  I  found  that  the  atrophied  mus- 
cles were  the  deltoid,  serratus  magnus,  and  biceps,  but  none  of  the  lower 
muscles  of  the  forearm  were  attacked.  The  man  had  consulted  another 
physician,  who  considered  the  case  one  of  chronic  rheumatism,  and  pre- 
scribed liniments  and  alkalies.  The  patient  was  an  upholsterer,  and  had 
been  obliged  to  use  his  right  arm  to  a  great  extent,  especially  in  ham- 
mering on  cornices,  and  putting  up  decorations  which  were  above  his 
head.  He  had  had  violent  pain  in  the  shoulder  for  some  months,  and 
subsequently  the  atrophy  began  in  the  deltoids.  When  I  saw  him  the 
head  of  the  humerus  was  promitient,  and  there  were  fibrillary  contrac- 
tions in  some  of  the  muscles  of  the  back.  When  the  upper  extremity  is 
affected,  it  will  be  found  that  when  the  forearm  is  flexed  the  belly  of  the 
biceps  wijl  be  often  found  to  be  reduced  to  the  size  of  a  small  ball.  The 
progress  of  the  disease  is  marked  by  the  occurrence  of  well-marked  inter- 
missions, and  a  year  or  two  may  often  pass  without  any  extension,  while 
at  the  end  of  that  time  a  fresh  start  is  taken,  and  two  or  more  of  these 
stationary  periods  are  not  uncommon  in  the  course  of  the  malady.  The 
ordinary  tendency  of  the  affection  is  however  progressive ;  and  although, 
as  I  have  said,  the  disease  may  pursue  the  most  eccentric  course,  attack- 
ing groups  of  muscles  here  and  there,  it  will  involve  ultimately  a  very 
great  number,  and  finally  those  supplied  by  the  lower  cranial  nerves,  un- 
less it  be  checked  by  proper  treatment. 

I  may  illustrate  the  symptomatology  of  progressive  muscular  atrophy 
by  a  case  which  ran  a  somewhat  irregular  course  by  attacking  the  muscles 
of  the  lower  extremities  : — 

J.  F.  H.,  31  years  old ;  U.  S. ;  engineer.  Twenty-one  months  ago  the 
patient,  after  exposure,  developed  what  he  says  was  articular  rheumatism, 
which  chiefly  affected  the  legs.  On  recovery  he  noticed  that  the  right 
leg  "  began  to  grow  smaller  at  the  calf,"  and  that  afterwards  his  left 
thigh  became  smaller.  His  pains  continued  at  intervals,  and  were  in- 
creased by  damp  weather. 

Present  Condition. — The  muscles  of  the  anterior  part  of  legs  and  thighs 


298 


DISEASES    OF    THE    SPINAL    CORD, 


are  much  wasted,  the  abductors  of  thighs  aad  the  recti  femoris  on  both 
sides  being  notably  so.  The  knees  seem  very  large,  and  the  condyles  of 
the  femur  are  felt  to  be  superficial  and  covered  tightly  by  the  skin.  There 
is  no  loss  of  sensation,  and  electric  irritibility  appaars  to  be  very  generally 
preserved,  except  in  the  recti  femoris.  The  glutei  muscles  have  suffered 
to  some  extent  on  both  sides.  He  has  severe  pain  at  night,  which  runs 
down  the  legs,  and  "  seems  to  be  deep."  There  is  impaired  motor  power, 
and  he  finds  that  walking  is  difficult.  He  does  not  experience  any  urinary 
trouble,  and  his  bowels  are  not  constipated.  There  is  no  loss  of  co-ordi- 
nating power,  no  constricting  band,  no  history  of  any  kind  of  acute  mye- 
litis. The  muscles  on  the  outer  side  of  the  thigh  are  the  seat  of  fibrillary 
contractions,  which  occur  sometimes  when  he  makes  a  voluntary  effort. 
There  was  at  this  time  no  atrophy  of  any  of  the  muscles  of  the  upper 
extremities,  but  when  I  saw  him  some  months  subsequently  there  was 
commencing  atrophy  of  the  muscles  of  the  right  hand.     In  the  paralyzed 

Fig.  45. 


Atrophy  of  the  Left  Shoulder. 

muscles  the  temperature  is  much  lowered,  and  this  is  a  constant  feature  of 
the  disease. 

Jaccoud^  and  others  have  called  attention  to  a  temperature  change, 
which  they  call  "  refroidissement  variable,"  in  which  there  are  times 
when  the  temperature  may  fall  several  degrees,  and  this  seems  to  be 
the  result  of  a  paroxysmal  ischremia  of  the  tissues.  The  pupillary  con- 
dition is  an  interesting  feature  of  the  disease,  the  dilators  sometimes  being 
paralyzed,  so  that  the  pupils  are  widely  or  unequally  dilated. 


1  Op.  cit.,  p.  326. 


PROGRESSIVE    MUSCULAR    ATROPHY.  299 

It  is  the  rule,  in  these  cases,  to  discover  certain  trophic  changes  affect- 
ing the  skin  and  its  appendages,  so  we  quite  commonly  find  diseases  of  the 
nails,  eruptions,  and  other  cutaneous  lesions ;  but  a  patient  now  under 
treatment  presents  something  in  addition  to  these.  It  has  been  found  that 
he  sweats  profusely  upon  the  right  side  of  the  body,  which  is  more  atro- 
phied than  the  left,  while  the  left  side  is  quite  dry. 

By  careful  experimentation  I  have  found  that  when  ammonia  is  held 
to  his  nose  the  right  eye  almost  immediately  becomes  suffused  with  tears, 
while  the  left  remains  almost  entirely  unaffected. 

When  salt  is  placed  upon  the  tip  of  the  tongue  an  abundant  discharge 
of  saliva  from  the  right  corner  of  the  mouth  occurs  almost  at  once. 

Dr.  Claddek,  my  assistant  at  the  Hospital,  painted  with  cantharidal 
collodion  two  spots  of  the  same  size  upon  either  side  of  the  chest,  and 
upon  the  normal  side  only  very  slight  changes  took  place,  while  upon 
the  right,  or  affected  side,  a  blister  was  formed  almost  immediately,  and 
it  was  very  slow  in  healing. 

In  many  cases  the  general  health  of  the  patient  is  unaffected  in  any 
way,  and  yet  the  atrophy  may  be  of  the  most  complete  nature.  I  recently 
saw  a  patient  thirty-eight  years  old,  who  had  been  a  soldier  in  the  regular 
army,  and  was  exposed  much  to  the  elements.  His  illness  has  lasted  but 
two  years,  yet  in  that  short  time  nearly  every  voluntary  muscle  has  under- 
gone a  great  diminution  in  size,  except  those  of  the  face.  His  respiration 
is  labored,  and  he  cannot  stand  without  support.  He  is  5  ft.  8  in.  in 
height,  and  his  anterior  dorsal  curve  is  four  inches  in  extent.  In  a  line 
measured  at  level  of  nipples  his  chest  girth  is  26  inches  ;  at  inspiration 
there  is  a  gain  of  two  inches.  The  right  arm  at  middle  'of  biceps  is  61 
inches  in  diameter;  the  left  62-  inches.  All  the  bony  prominences  are 
distinct,  the  angles  of  the  scapulae  approximate,  and  he  is  almost  a  skele- 
ton in  appearance.     There  is  no  loss  of  sensation : 

The  atrophy  in  this  case  was  as  great  as  that  presented  by  Duchenne's 
patient,  ^  Bonnard,  in  which  the  pectoral,  trapezii,  with  the  exception  of 
their  clavicular  portion,  great  muscles  of  the  back,  biceps  and  anterior 
muscles  of  the  left  arm,  supinatores  longii,  had  nearly  entirely  disap- 
peared. 

Duchenne  alludes  to  the  changes  in  conformation  of  the  thorax  when 
the  intercostals  or  diaphragm  are  paralyzed,  and  presents  two  illustrations 
showing  the  perimeter  of  the  chest  in  two  patients  affected  with  atrophy. 
These  are  presented  in  the  accompanying  illustrations.  Thoracic  troubles, 
such  as  bronchitis,  are  not  uncommon  as  a  result  of  impaired  lung  action. 

Causes. — These  may  be  enumerated  as  heredity,  which  is  found  to 
enter  conspicuously  into  the  etiology  of  progressive  muscular  atrophy, 
exposure,  the  over-use  of  2^(ii't'icular  groups  of  muscles,  injury  of  the  spinal 
cord,  and  sometimes  syphilis  and  the  zymotic  diseases.  As  to  the  heredi- 
tary influence  which  favors  its  development,  Friedreich  '^  reports  several 
cases,  which  go  to  show  that  this  disease,  more  than  all  others,  commonly 

1  Op.  cit.,  3rd  ed.,  p.  500.  2  Qp.  cit. 


300  DISEASES    OF    THE    SPINAL    CORD, 

Fig.  U. 


(Duchenne.) 

appears  in  several  generatious  of  the  same  family.  I  have  seen  one  case 
where  it  could  be  traced  for  three  generations  back,  and  in  another,  which 
I  will  presently  detail,  there  were  uncles  and  aunts  affected.  Eichert,^ 
in  a  very  valuable  article,  gives  the  family  history  of  one  case.  In  a 
genealogical  table  he  traced  the  disease  back  six  generations,  and  repre- 
sentatives of  these  generations  are  still  living.  Seven  cases  are  related 
by  him.  In  two  of  the  cases  the  parents  have  escaped,  while  the  children 
have  suffered.  It  is  unnecessary  to  pursue  this  matter  further  ;  but  I  am 
firmly  convinced  that  there  is  no  other  disease,  except  perhaps  it  may  be 
phthisis  pulmonalis,  which  is  transmitted  so  frequently  as  this  terrible 
malady.  Exposure  to  damp,  neglect  to  change  wet  clothing,  and  like 
imprudences,  are  exciting  causes  in  many  cases.  Neuralgic  pains  are 
very  prominent  in  such  cases,  and  the  onset  of  the  disease  is  rather  pre- 
cipitate. Mechanics  of  all  kinds,  who  are  in  the  habit  of  using  some 
muscles  much  more  than  others,  are  frequently  the  victims  of  the  disease, 
and  the  muscles  which  have  been  over-used  are  aflfected  before  the  others. 
I  have  seen  the  same  limited  atrophy  in  a  cigar-maker  and  in  a  composi- 
tor, who  used  certain  groups  of  muscles  almost  constantly.  Roberts  has 
dwelt  upon  the  connection  between  injury  of  the  spinal  cord  and  the  dis- 
ease under  consideration ;  and  Valeutiner,^  Bergmann,^  and  Thudicum 
have  all  called  attention  to  the  appearance  of  the  disease  some  time  after 
the  receipt  of  an  injury.  Roberts  reports  a  case  in  which  atrophy  of  the 
ball  of  the  right  thumb,  and  subsequent  complication  of  the  respiratory 
muscles,  and  death  followed  a  slight  injury  received  six  months  before. 
The  other  cases  are  none  the  less  interesting,  and  go  to  prove  the  import- 
ance of  recognizing  such  causes.  As  to  age  and  sex,  it  has  been  found 
that  progressive  muscular  atrophy  is  not  confined  to  any  period  of  life, 
but  the  bulk  of  cases  occur  after  puberty.  Of  88  cases  reported  by 
Roberts,  1  Avas  only  2  years  old,  and  another  69.  Of  the  28  cases  I  have 
seen,  the  atrophy  began  in  2  between  the  5th  and  10th  years;  in  5, 
between  the  10th  and  15th ;  in  18,  between  the  20th  and  the  30th ;  and 
in  3  after  the  30th.     Of  these,  23  were  men,  and  but  5  women.     This 

1  Prag.  Viert.,  1855.  -  Berliner  Klin.  Wochenschrift,  Oct.  20,  1874. 

*  Petersburg  Med.  Zeitsch.,  1864. 


PROGRESSIVE    MUSCULAR    ATROPHY.  301 

seems  to  be  the  rule,  and  Roberts  states  that  six  men  are  affected  to  every 
woman,  and  he  considers  this  due  to  the  exposure  and  external  violence 
to  which  males  are  subjected. 

Morbid  Anatomy  and  Pathology. — The  disputed  point  in  regard 

to  the  pathology  seems  to  be  whether  it  is  a  primary  peripheral  condition, 
or  whether  it  is  a  central  affection  in  which  the  trophic  cells  are  affected. 
The  advocates  of  the  first  theory  call  attention  to  the  fact  that  muscular 
atrophy  occurs  independent  of  any  loss  of  the  muscular  function,  and 
believe  it  to  be  purely  a  local  degeneration.  The  authorities  I  have 
spoken  of,  in  alluding  to  the  early  history  of  the  disease,  all  believed  in 
this  intra-muscular  origin  ;  but  lately  there  have  been  so  many  proofs  of 
its  central  origin  brought  forward,  that  the  former  theory  has  been  aban- 
doned. This  difference  of  opinion  seems  to  exist  in  regard  to  the  form  of 
central  lesion.  The  majority  of  observers  are  agreed  that  there  is  an 
affection  of  the  anterior  horns ;  and  that  the  change  is  one  that  affects 
the  trophic  cells  of  Duchenne  and  Westphal,  and  the  fibres  which  con- 
nect with  sympathetic  ganglia. 

To  Lockhart  Clarke,^  who  has  so  often  decided  questions  regarding  the 
pathology  of  nervous  disease,  belongs  the  credit  of  having  discovered  the 
central  origin  of  this  disease.  He  found  atrophy  of  the  anterior  gray 
horns,  and  since  his  original  observations  many  other  o'bservers  have 
come  forward  to  endorse  his  views.  Von  Recklinghausen  and  Dumenil'* 
disagree,  however,  with  this  view,  and  the  microscopical  examination 
made  by  the  former  was  unattended  with  any  discovery  of  morbid  appear- 
ances. 

Jaccoud  has  collected  six  cases  in  which  fatty  degeneration  of  the 
sympathetic  had  taken  place,  and  one  of  them  was  observed  by  this  author 
himself.  Not  only  was  there  fibro-fatty  degeneration  of  the  sympathetic 
nerve,  but  there  was  atrophy  of  the  anterior  roots.  The  view  held  by 
Jaccoud  is  that  the  trophic  filaments  of  the  sympathetic  which  preside 
over  nutrition  do  not  perform  their  duty,  and  that  the  affection  of  a 
mixed  nerve,  which  contains  motor,  sensor,  and  trophic  filaments,  at  a 
point  where  they  are  intimately  mixed,  must  result  in  a  perversion  of  all 
their  functions ;  but  if  the  separate  filaments  be  attacked  at  a  point  be- 
fore they  become  blended,  there  may  be  independent  loss  of  function  of 
either  one.^ 

Charcot  and  Gombault*  have  described  the  following  interesting  post- 
mortem appearances  witnessed  in  a  recent  case : — 


1  Brit,  and  For.  Med.-Chir.  Eeview,  vol.  xsx.,  1862.  ^  Gaz.  Hebdom.,  1867. 

^  The  localization  of  well-defined  lesions  in  this  disease  is  sometimes  made  before 
death  and  verified  afterwards.  Prevost  and  Cotard  (Archives  de  Physiol.,  Sept., 
1874)  present  such  a  case.  There  was  atrophy  of  the  right  thenar  eminence,  with 
atrophy  of  the  right  anterior  root  of  the  eighth  pair  of  cervical  nerves,  slightly 
marked  atrophj'  of  the  right  anterior  root  of  the  seventh  cervical  nerves,  and  atrophy 
of  the  gray  matter  of  the  anterior  horn  at  this  level  of  about  an  inch  in  extent. 

*  Archives  de  Physiol.,  1875,  No.  5,  abst.  Phil.  Med.  Times. 


302  DISEASES    OF    THE    SPINAL    CORD. 

"No  change  in  hemisphere,  cerebellum,  pons,  or  medulla  oblotigata  in 
these  nerves.  The  gray  substance  of  the  cervical  and  dorsal  medulla 
spinalis  was  greatly  altered  from  the  lower  portion  of  the  cervical  enlarge- 
ment down,  gradually  decreasing  downwards  and  outwards.  The  nerve- 
cells  and  nerve-fibres  of  the  anterior  gray  cornua  had  disappeared;  the 
capillary  vessels  were  greatly  developed ;  the  parietes  of  the  smaller  and 
larger  vessels  were  thickened.  The  lumbar  portion  of  the  cord  and  the 
lateral  columns  were  normal.  In  the  cervical  and  dorsal  region,  the 
portions  of  the  cord  near  the  merging  external  roots  were  sclerosed ;  the 
change  being  proportionate  to  the  intensity  of  that  which  had  taken 
place  in  the  gray  cornua.  The  few  ganglion-cells  present  were  very 
much  diminished  in  size,  without  processes,  more  rich  in  pigment  than 
normal,  but  still  containing  nuclei  and  nucleoli.  The  anterior  roots  of 
the  cervical  region  were  atrophic ;  empty  sheaths,  frequently  containing 
large  nuclei,  appeared  in  place  of  the  normal  fibrillar  contents.  The 
posterior  roots  seemed  normal. 

"  As  to  the  peripheral  nerves,  one  phrenic  and  several  intercostal 
nerves  were  examined ;  more  than  two-thirds  of  the  nerve-tubules  (in 
hardened  sections)  were  wanting,  by  a  process  similar,  as  it  would  ap- 
pear, to  that  induced  by  an  external  wound.  The  muscles  about  the 
shoulder  and  the  upper  extremities  were  for  the  most  part  atrophic  ; 
there  seemed  to  be  a  peculiar  atrophy  of  the  primitive  fasciculi,  without 
any  marked  alteration  in  the  fibrils,  and  without  any  excessive  develop- 
ment of  the  interfibrillar  fatty  tissue." 

The  changes  discovered  by  Clarke'  were  in  the  gray  matter.  There 
was  a  granular  deposit  about  the  vessels,  and  corpora  amylacea  about  the 
central  canal.  Lesions  of  the  anterior  nerve-roots  were  found,  and  in  the 
cervical  region  there  seemed  to  be  more  distinct  appearances  than  at  any 
other  point,  where  it  will  be  remembered  there  may  be  found  sympathetic 
as  well  as  motor  and  sensor  fibres. 

The  muscles  present  distinct  evidences  of  fatty  degeneration  and  fatty 
substitution.  They  appear  to  the  naked  eye  as  wasted  bands  which  con- 
tain lines  of  fat.  The  appearance  of  healthy  muscles  of  good  contour  in 
juxtaposition  with  others  which  have  undergone  atrophy  is  very  peculiar, 
and  it  is  difficult  to  realize  that  the  disease  can  involve  such  isolated 
tracts.  The  muscles  of  the  lower  extremities  may  have  undergone  general 
fatty  degeneration.  A  specimen  prepared  by  my  friend  Dr.  Weisse,  of  the 
Medical  department  of  the  N.  Y.  University,  shows  very  beautifully  this 
condition  of  affairs.  Fatty  substitution  has  gone  on  to  such  an  extent 
that  there  ia  no  appearance  of  muscular  fibre  to  be  seen,  but  every  muscle 
exists  as  a  distinct  band  of  adipose  tissue.  Atrophied  muscles  have  been 
examined  by  Meryon,^  Galliet,^  and  others,  and  their  descriptions  of  ap- 
pearances agree  very  closely.  The  muscular  structure  suffers  a  complete 
change,  the  strice  disappearing  and  the  sarcolemma  undergoing  a  granular 
change.     Fox*  divides  the  secondary  changes  into  the  fatty  degeneration 

1  Med.  Chir.  Trans.,  1851,  1856. 

"  Ibid.,  1866. 

'  Archives  G^n.,  vol.  i.,  5me  R^rie,  1853,  p.  584. 

*  Op.  cit.,  p.  266,  et  seq. 


PROGRESSIVE    MUSCULAR    ATROPHY.  303 

whicli  takes  place  inside  of  the  sarcolemma,  and  as  an  interstitial  deposit. 
These  he  calls  the  parenchymatous  and  the  interstitial.  Sometimes,  as 
observed  by  Robin,  the  atrophy  may  take  place  as  a  fibrous  degeneration, 
or  species  of  muscular  sclerosis.  Some  muscles  appear  as  fibrous  cords  of 
a  white  color,  while  others  may  be  found  which  have  undergone  the  fatty 
degeneration  just  described. 

An  instructive  case  in  which  very  striking  appearances  were  presented 
was  observed  by  Dr.  Janeway,  whose  observations  are  recorded  below  : — 

M.  G.,  aged  62  years,  widow ;  admitted  to  hospital  December  16th, 
1873.  Right  hand  :  the  muscles  of  ball  of  thumb  are  very  much  atro- 
phied, and  she  is  unable  to  move  it ;  there  is  also  slight  rigidity  of  the 
joints  of  the  thumb. 

Dorsal  interossei  are  very  much  wasted;  there  is  slight  power  of  flexion 
and  extension  of  fingers,  especially  Jittle  fingers,  and  there  is  also  a  slight 
movement  at  the  wrist. 

Sensibility  good  except  in  index  finger,  and  here  it  is  decided Ij''  dimin- 
ished. She  can  raise  her  arm  to  her  head  and  place  it  in  any  position. 
Hands  seem  cold. 

Left  hand  is  not  so  much  affected  ;  the  muscles  of  ball  of  thumb  are 
partially  wasted.  The  abductor  opponens  and  outer  head  of  flexor  brevis 
are  almost  gone ;  the  inner  head  of  flexor  brevis  and  abductor  partially, 
and  capable  of  acting  to  a  slight  extent.  Has  slight  power  of  ab-  and  ad- 
duction of  fingers,  especially  the  little  finger,  most  on  the  ulnar  side,  and 
decreasing  toward  the  radial ;  has  slight  power  of  extension  over  fingers, 
none  over  thumb,  but  flexioQ  power  is  more  marked.  Has  no  power  of 
extension,  but  considerable  of  flexion  at  the  wrist. 

Dynamometer  L.  H.  28.  Sensibility  normal ;  hands  cold.  The  mus- 
cles that  are  capable  of  acting  respond  to  the  induced  current  very  well. 

July  9.  Complains  of  dizziness  and  nausea 

nth.  Dizziness  still.  Her  hands  are  in  same  condition.  She  expe- 
riences some  difficulty  in  walking,  and  moves  with  her  body  ''  sloping 
over  "  She  cannot  use  her  hands,  and  when  she  attempts  to  do  any- 
thing, they  drop,  and  she  cannot  raise  them.  The  muscles  that  remain 
unaffected  respond  well  to  electricity.  She  still  vomits  at  times  after 
eating. 

August  3    Is  quite  weak  ;  has  chilly  sensations. 

4:ih.  Had  a  severe  fever  last  night ;  temperature  104°  ;  passed  feces 
in  bed,  and  did  not  know  it;  to-day  temperature  is  almost  normal ;  is  quite 
apathetic. 

5th.  Has  chilly  sensations  ;  complains  of  no  pain ;  arms  and  jaws  trem- 
ble; temp.  102°. 

2  P.  M.  Temp.  102°. 

Qth.  She  is  very  much  worse ;  mucous  rales  heard  all  over  chest ;  respi- 
ration accelerated  ;  temp,  high  ;  pulse  very  feeble ;  pupils  normal ;  bowels 
moved  once  to-day  ;  swallows  with  great  difiiculty. 

2.  P.  M.  She  sank  gradually  and  died  at  12.45  P.  M. 

Post-mortem,  held  twenty-seven  hours  after  death. — Rigor  mortis  mode- 
rately well  marked.  Nearly  all  the  muscles  of  the  hands  are  atrophied, 
especially  the  dorsal  interossei  and  the  propria  muscles  of  the  thumb  ;  the 
change  is  nearly  symmetrical  in  both  hands.  The  forearms  are  extremely 
wasted,  both  on  the  flexor  and  extensor  surfaces.     There  is  no  marked 


304  DISEASES    OF    THE    SPINAL    CORD. 

wasting  in  the  arms,  the  shoulders  are  well  rounded  ;  both  pectoral  regions 
appear  wasted ;  there  is  no  marked  wasting  in  the  lower  extremities,  un- 
less it" be  in  the  adductor  region  of"  both  thighs.  Incisions  made  into  the 
pectoral  muscles,  show  well-colored  fibres  also  in  the  deltoid,  biceps,  and 
triceps. 

The  extensors  of  the  forearms  are  of  whitish-yellow  color,  being  nearly 
as  pale  as  the  skin. 

The  flexors  of  right  hand  are  very  much  wasted,  but  not  so  much  as 
the  extensors.  The  flexors  of  the  left  side  are  small,  but  seem  in  good 
condition. 

The  muscles  of  the  right  thenar  eminence  show  extreme  degeneration. 
In  left  thenar  eminence  the  inner  head  of  flexor  brevis  and  adductor  are 
red  and  large;  the  external  is  white,  as  on  the  other  side.  The  adductors 
of  thighs  are  small,  but  well-colored. 

The  quadriceps  extensor  femoris  is  of  good  color. 

The  anterior  tibial  muscles  are  of  good  color. 

Heart:  Valves  are  normal,  muscular  substance  soft,  and  yellowish- 
gray.     The  diaphragm  is  not  atrophied. 

Brain :  Convolutions  and  corpora  striata  appear  normal.  There  is 
some  atheroma  of  the  carotid  and  basilar  arteries. 

The  substance  of  the  cord  and  brain  is  quite  soft.  The  viscera  are  nor- 
mal, except  the  kidneys,  and  these  are  granular;  their  pyramids  are 
small,  and  they  contain  small  cysts. 

Diagnosis. — Progressive  muscular  atrophy  may  be  mistaken  for  seve- 
ral conditions  of  a  paralytic  nature,  among  these  lead  paralysis,  antero-la- 
teral  sclerosis,  partial  paralysis  from  traumatism,  and  infantile  or  adult 
paralysis. 

For  an  illustration  of  the  first  of  these  I  do  not  think  I  can  do  better 
than  mention  a  case  in  which  there  appeared  to  be  lead  paralysis,  but 
which  subsequently  turned  out  to  be  progressive  muscular  atrophy. 

Several  months  ago,  Mr.  N.,  a  Cuban  gentleman,  came  to  me  with  a 
letter  from  his  medical  adviser,  Dr.  Findlay,  of  Havana.  The  doctor's 
history  of  the  patient  is  as  follows :  "  Mr.  N.,  about  eighteen  months 
ago,  began  to  experience  a  tremor  in  the  fingers  and  wrist  of  the  right 
hand,  together  with  muscular  debility,  which  caused  some  inconvenience 
in  writing,  and  in  carrying  food  to  his  mouth,  as  well  as  in  other  move- 
ments of  the  hand.  Having  on  a  single  occasion  submitted  to  local  fara- 
dization of  the  arm  (some  ten  months  ago),  the  tremor  was  much  sub- 
dued, and,  as  was  thought,  the  fingers  and  wrist  were  strengthened.  It 
was  not,  however,  until  four  months  ago  that  the  patient  returned  to  put 
himself  under  a  regular  course  of  treatment. 

"  Condition  of  the  patient  in  July,  1876. — General  health  good ;  no 
signs  of  cachexia  ;  no  antecedents  of  specific  taint ;  no  lead  poisoning. 
Sufl^ered  on  two  or  three  occasions,  at  some  years'  interval,  rheumatic 
pains  and  neuralgia  in  the  arm  and  shoulder  of  the  left  side,  but  never  in 
the  right  side,  which  is  the  one  now  affected.  The  outer  appearance  of 
the  right  arm  showed  but  little  muscular  atrophy ;  the  tremor  was  incon- 
siderable ;  the  patient  could  close  the  hand  tightly,  but  not  well  grasp 
larger  objects,  such  as  a  tumbler,  owing  to  incapacity  to  maintain  the  first 


PROGRESSIVE    MUSCULAR    ATROPHY.  305 

phalanx  of  the  third,  fourth,  and  fifth  fingers  extended.  The  wrist  was 
inclined  to  drop  forwards  (in  flexion)  and  outwards. 

"  On  inspection  it  was  found  that  the  common  extensor  of  the  fingers 
was  considerably  weakened,  most  so  in  the  portion  attached  to  the  ring- 
finger,  the  weakness  being  manifested  both  to  voluntary  and  to  electrical 
contractility.  The  same  condition  existed  also,  though  a  little  less,  in  the 
extensor  of  the  little  finger,  and  in  the  radial  extensors.  The  contractil- 
ity was  not  totally  absent,  but  would  vary  in  degree  without  apparent 
cause.  The  disease  continued  to  progress  (notwithstanding  treatment),  the 
portions  of  the  common  extensors  losing  all  excitability  to  my  small 
Gaiffe's  battery,  and  the  extensors  of  the  thumb  being  also  implicated. 

"  The  left  arm  was  now  examined,  and  although  the  patient  did  not 
notice  any  weakness  in  the  hand,  yet  some  deficiency  of  electric  contrac- 
tility was  observed  in  the  common  extensor,  especially  in  the  extensor 
of  the  ring-finger.  The  constant  current  was  now  used  for  six  weeks 
without  much  benefit.  The  extensor  carpi  ulnaris  is  now  becoming  also 
afiected.  The  patient,  however,  finds  that  he  can  write  and  perform 
various  acts  with  the  right  hand  better  than  before.  Within  the  last 
week  he  complains  of  some  pain  along  the  back  of  the  left  forearm  when 
he  has  been  holding  an  object  in  the  air,  and  feels  an  inclination  to  relax 
his  grasp." 

The  doctor  also  gave  a  history  of  hereditary  trouble,  which  was  proba- 
bly in  one  case  (the  patient's  uncle)  progressive  muscular  atrophy. 

I  carefully  examined  the  patient,  and  found  that  the  right  arm  was 
that  most  affected. 

Motor  jjower. — The  power  of  extension  of  the  muscles  of  the  right 
forearm  was  lost  completely,  and  on  the  left  side  the  power  of  exten- 
sion of  the  two  middle  fingers  was  to  some  degree  impaired.  Flexion 
was  perfect. 

Atrophy. — The  following  muscles  were  more  or  less  affected  and  re- 
duced in  size.  Right  forearm  :  Extensor  communis  digitorum  ;  extensor 
minimi  digiti ;  extensor  carpi  radialis  ;  extensor  longis  pollicis ;  extensor 
carpi  ulnaris  ;  extensor  communis  of  the  left. 

Sensation. — Slightly  impaired  on  the  right  side.  The  teeth  of  the 
sesthesiometer  were  separated  by  a  space  of  about  ten  centimetres  before 
two  points  could  be  appreciated.  This  loss  was  not  so  great  on  the  under 
surface  of  the  forearm.  There  was  no  history  of  recent  pain  either  con- 
stant or  neuralgic,  nor  were  there  any  dyssesthetic  sensations. 

No  fibrillary  contractions  were  observed.  There  was  a  slight  tremor 
in  the  right  hand  when  voluntary  movements  were  made.  Electric  con- 
tractility to  a  very  slight  degree  was  observed  in  the  extensor  communis 
digitorum  when  a  strong  faradic  current  was  applied.  The  galvanic  cur- 
rent also  seemed  to  have  some  influence  upon  the  weakened  muscles.  The 
fingers  were  covered  by  small  flakes  of  skin,  and  the  nails  were  crenated, 
irregular,  and  evidently  badly  nourished.  This  trophic  defect  disappeared 
under  the  use  of  the  galvanic  current. 

Diagnosis- — In  the  order  I  name  them  I  proceeded  to  dispose  of  lead 
paresis,  amyotrophic  sclerosis,  cerebral  paralysis,  traumatic  paralysis,  and 
progressive  muscular  atrophy. 

That  it  might  be  lead  paresis  seemed  reasonable  at  first,  because  of  the 
loss  of  electric  contractility,  the  seat  of  the  paralysis,  etc  ;  but  when  I  bore 
in  mind  that  the  trouble  was  one-sided  at  first,  that  there  was  a  subse- 
quent invasion  of  the  muscles  of  the  other  arm,  that  sensibility  was  also 
20 


306  DISEASES    OF    THE    SPINAL    CORD. 

impaired,  and  that  the  patient  used  neither  hair-dye  nor  drank  impure 
water,  nor  was  expo.^ed  to  the  dangers  of  lead  poisoning  of  any  kind,  I 
was  forced  to  abandon  this  idea.  A  species  of  spastic  contraction  drew 
down  the  fingers  of  the  right  hand  and  tliere  was  some  cumulative  tre- 
mor, such  as  characterizes  sclerosis  (expressed  by  a  gradually  increased 
tremor,  aggravated  by  will  control,  and  terminating  in  a  species  of 
spasm).  This  at  first  led  me  to  suppose  that  there  might  be  some  degene- 
ration of  the  lateral  columns,  but  as  the  tremor  disappeared  and  there 
■were  no  other  symptoms  of  such  degeneration,  and  especially  as  there  was 
gradual  atrophy  and  muscular  paralysis,  I  dismissed  this  possibility.  The 
loss  of  electric  contractility,  and  the  limited  field  of  the  paralysis,  ex- 
cluded cerebral  paralysis  ;  and  the  fact  that  the  patient  had  never  received 
an  injury,  and  that  the  affection  was  beginning  to  affect  the  opposite 
group,  negatived  the  theory  of  traumatic  paralysis.  All  that  was  left 
was  the  diagnosis  of  progressive  muscular  atrophy ;  and  the  subsequent 
appearance  of  fibrillary  contractions  made  me  quite  sure  of  my  decision. 
The  slow  progress  of  the  trouble  and  its  site  were,  however,  doubtful 
points.  The  individual  had  not  exercised  any  particular  member,  and 
as  he  was  a  man  of  leisure,  there  was  no  trade  or  occupation  in  which 
constant  use  of  the  hands  or  excessive  labor  was  required  that  could  ac- 
count for  its  origin.  The  hands  preserved  their  contour ;  there  was  no 
atrophy;  no  prominent  thenar  eminences;  nothing  suggestive  of  the 
main  en  griffe.  Xone  of  the  muscles  of  the  back  were  affected,  and  the 
deltoids  were  of  good  volume  and  power.  The  fact  that  others  in  his 
family  had  suffered,  that  the  disease  began  on  one  side  and  extended  to 
the  other,  that  fibrillary  contractions  were  present,  that  subsequently  I 
■was  enabled  to  get  slight,  and  afterwards  stronger  contractions  of  the 
.paralyzed  and  atrophied  muscles,  determined  me  in  my  diagnosis  of  this 
anomalous  case.  I  call  it  anomalous,  because  I  have  been  taught,  and 
my  own  experience  convinces  me,  that  this  is  a  very  rare  seat  of  pro- 
gressive muscular  atrophy.  Protean  as  is  the  malady,  I  have  not  seen 
paralysis  of  the  extensors,  as  a  primary  symptom,  in  any  one  of  the 
twenty  eight  cases  of  the  affection  I  have  met  with  from  time  to  time. 

In  lead  paresis  the  invasion  is  rapid,  the  paralysis  the  same,  and  the 
atrophy  is  secondary,  which  is  not  the  case  in  the  wasting  palsy.  There 
is  sometimes  the  lead  line  or  lead  colic,  and  electric  contractility  is  im- 
paired from  the  first.  From  traumatic  paralysis  it  can  be  diagnosed  by 
the  irregularity  in  situation  of  the  muscles  atrophied.  In  traumatic 
paralysis  we  may  look  for  atrophy  of  groups  of  muscles  which  are  sup- 
ported by  a  common  trunk,  as  well  as  loss  of  electric  contractility  and 
secondary  atrophy. 

The  diagnosis  from  some  forms  of  adult  and  infantile  paralysis  is  not 
so  easy.  In  fact  Duchenne  believed  the  pathology  of  the  two  affections 
to  be  nearly  the  same.  The  sudden  origin  of  the  infantile  cases  of  course 
precludes  any  mistake  in  the  majority  of  cases,  but  in  adult  cases  even 
after  the  disease  has  existed  for  some  time. 

In  such  cases  the  paralysis  and  atrophy  may  co-exist  to  a  dispropor- 
tionate degree.  If  it  is  possible,  however,  to  ascertain  the  early  occur- 
rence of  paralysis,  and  if  the  loss  of  muscular  substance  be  rather  general, 
no  mistake  need  be  made. 


PROGRESSIVE    MUSCULAR    ATROPHY.  307 

Prognosis. — Occasionally  the  malady  may  be  arrested  or  cured  en- 
tirely, and  this  fact  seems  almost  incredible  when  we  bear  in  mind  its 
organic  character.  The  duration  of  the  disease  is  variable.  Some  of 
these  patients  recover,  while  in  other  cases  it  runs  its  course  in  from  five  to 
twenty  years,  the  atrophy  meanwhile  involving  fresh  groups  of  muscles 
with  more  or  less  rapidity. 

In  a  case  shown  at  my  clinic,  the  disease  had  lasted  for  two  years,  and 
the  atrophy  had  involved  nearly  all  the  muscles  of  the  upper  part  of  the 
body.  In  another  patient  I  have  recently  seen,  the  disease  has  progressed 
very  little  during  the  last  ten  or  twelve  years. 

I  have  succeeded  in  arresting  the  disease  in  ten  cases,  and  think  that, 
when  there  is  the  least  muscular  response  to  electricity,  there  is  still  a 
chance  for  improvement,  if  not  complete  relief.  This  is,  of  course,  in 
proportion  to  the  extent  of  invasion.  If  the  atrophy  be  confined  to  the 
muscles  of  one  forearm,  there  need  be  no  reason  to  give  a  bad  prognosis. 
The  majority  of  cases,  however,  go  on  to  an  unfavorable  termination, 
and  perhaps  one  reason  is,  that  patients  delay  so  long  to  seek  medical 
advice,  considering  their  disease  to  be  rheumatism,  and  amenable  to  do- 
mestic treatment.  When  the  diaphragm  or  the  intercostales  are  invaded, 
the  prognosis  is  as  bad  as  it  well  can  be. 

Roberts^  thinks  that  the  prognosis  is  bad  when  hereditary  predisposi- 
tion can  be  traced,  or  when  the  upper  and  lower  extremities  are  both 
implicated. 

Treatment. — I  know  of  no  other  remedies  than  those  which  are  local 
(except  when  a  syphilitic  taint  is  suspected).  Electricity  is  one  of  these  ; 
muscular  rest  is  the  second  when  the  affection  has  followed  over-use  of 
certain  muscles. 

The  galvanic  current  from  not  less  than  twenty  cells  should  be  used, 
one  electrode  being  placed  over  the  nucha,  and  the  other  in  the  supra- 
clavicular space.  Applications  of  ten  minutes  every  day  cannot  fail  to  do 
good.  In  addition  to  this,  the  faradic  current  should  be  employed  for 
the  muscles  themselves,  making  each  muscle  contract  several  times,  and 
then  allowing  it  to  rest,  and  repeating  the  operation  some  minutes  after- 
wards. Violent  electrization,  I  am  convinced,  fatigues  these  crippled 
muscles,  and  does  more  harm  than  good. 

Duchenne  gives  the  following  directions  for  the  use  of  the  induction 
current :  "  Place  the  wet  electrodes,  so  that  they  are  as  near  together  as 
possible  upon  the  surface  of  each  of  the  diseased  muscles,  using  an  induc- 
tion current  of  greater  or  less  tension,  so  that  all  the  anatomical  elements 
of  the  muscle  shall  be  excited.  Excite  the  muscles  generally  and  mode- 
rately and  apply  an  intermitted  current.  Faradize  only  the  atrophied 
muscles  which  still  respond  to  electric  excitation,  among  the  latter,  fara- 
dize by  preference  those  which  enter  most  frequently  and  usefully  into 
important  muscular  movements.     End  each  seance  by  the  slow  faradiza- 

^  Art.  Wasting  Palsy,  Reynolds's  System  of  Medicine,  American  Edition,  vol,,  i., 
p.  796. 


308  DISEASES    OF    THE    SPINAL    CORD. 

tion  of  the  more  important  muscles  among  those  threatened  by  the  inva- 
sion of  atrophy." 

Vivian-Poore  and  Fagge^  have  had  wonderful  success  with  this  agent, 
and  have  cured  a  number  of  apparently  hopeless  cases.  I  have  been 
induced  to  try  the  "  rubber  muscle,"  as  arranged  for  lead  paresis.  This 
forms  an  admirable  means  for  support  of  the  hands,  should  the  extensors 
be  affected,  as  was  the  case  in  the  history  I  have  just  related.  In  every 
case  it  is  well  to  insure  perfect  rest,  if  possible,  for  all  affected  muscles. 
If  the  muscles  of  the  shoulder  be  so  atrophied  as  to  allow  the  arm  to 
drop,  it  is  well  to  arrange  some  contrivance  to  sustain  its  weight,  and 
relieve  the  strain  upon  the  affected  organs.  Sulphur  baths  and  mineral 
waters  have  been  recommended,  and  in  some  hands  have  been  successful. 

PAETIAL  FACIAL  ATROPHY. 

Synonyms. — Trophic  neurosis  of  the  face  (Romberg) ;  Laminar 
aplasia  (Lande)  ;  Unilateral  progressive  atrophy  of  the  face  (Eulenburg'*;. 

Definition. — A  disease  of  a  trophic  nature,  involving  usually  one 
side  of  the  face,  beginning  with  discoloration  and  cutaneous  changes,  and 
ending  in  loss  of  tissue  of  underlying  cellular  tissue  and  bone,  not  accom- 
panied by  loss  of  motor  power  or  sensibility. 

The  disease  was,  according  to  Eulenburg,  first  described  by  Parry  ^  in 
1825,  and  afterwards  described  by  Bergsou*  in  1837. 

It  subsequently  received  attention  from  Romberg,^  Lande,*  Samuel,' 
Eulenburg,*  Fremy,®  Moore'"  and  others,  who  described  many  cases. 
Eleven  cases  are  reported  by  Lande  alone.  The  first  American  case  was 
presented  by  Dr.  Draper"  before  the  New  York  Society  of  Xeurology, 
Dec.  20,  1875,  and  other  cases  have  been  brought  forward  since  by  Se- 
guin,  Robinson,  Bannister  and  others.'^ 

A  photograph  of  Dr.  Draper's  case  is  presented  below. 

The  patient,  who  was  a  stout,  hearty  Irish  girl,  aged  18,  and  without 
any  hereditary  predisposition,  presented  herself,  with  the  following  his- 
tory :  About  two  years  ago  the  muscles  under  the  body  of  the  lower  jaw 
of  the  left  side  began  to  diminish  in  size,  and  after  a  few  months  there 

I  London  Practitioner,  December,  1868. 
2,Ziemsseu's  Cyclopaedia,  p.  57,  vol.  xiv. 
3  Quoted  in  Eulenburg's  article. 

*  De  prosopodj'smorphia  sive  nova  atrophise  facialis  specie,  Berlin,  1837. 
»  Klinische  Ergebnisse,  1846,  and  Klinische  Wahremung,  etc.,  1851. 
®  Essai  sur  I'aplasie  lamineuse  de  la  face  en  particulier  these  de  Pari.s,  1869- 
''  Die  trophischen  ^serven,  Leipzig,  1860. 

8  Wiener  Med.  Wocli.  und  Lehrbuch  der  functionellen  Xervenkrankheiten,  1871. 

9  Etude  critique  de  la  trophonevrose,  Paris,  1873. 

10  Dublin  Quarterly  Journal,  1852. 

II  Am.  Psychological  Journal,  Feb.,  1876.  Also  consult  recent  cases  in  Bull,  de  la 
Soc.  de  Chirurgie,  vol.  2,  1876.  Gaz.  Hebdomidaire,  No.  13,  p.  196,  1876.  Br. 
Med.  Journal,  Aug.,  1876. 

1'  Journal  of  Nervous  and  Mental  Diseases,  1876,  vol.  i. 


PARTIAL    FACIAL    ATROPHY.  309 

was  gradual  extension  of  the  atrophy,  so  that  finally  a  district  bounded 
by  the  symphisis  of  the  lower  jaw,  angle  of  the  nose,  and  middle  of  the 
upper  lip  in  front,  lower  edge  of  zygoma  above,  and  ramus  of  the  inferior 
maxillary  behind,  became  entirely  affected.  The  skin  is  bound  down  to 
the  periosteum  of  the  lower  jaw,  and  is  shiny,  tense  and  white.  There 
never  has  been  pain  of  any  kind,  but  the  only  sensory  alteration  occurred 
in  the  beginning,  when  a  slight  itching  was  felt.  There  is  no  anaesthesia 
anywhere,  not  even  in  the  tongue,  one  side  of  which  is  markedly  atro- 
phied. In  the  beginning  there  were  occasional  cramp-like  pains  about 
the  insertion  of  the  masseter  muscles  on  the  left  side,  but  none  on  the  other. 
There  was  slight  paresis  in  some  of  the  muscles  involved. 

Fig.  46. 


Partial  Facial  Atrophy. 

In  twelve  Continental  cases  collected  by  Draper,  eight  of  whom  were 
women  and  four  men,  the  atrophy  appeared  in  one  at  three  years  of  age, 
and  in  another  at  twenty-two  years  of  age.  The  beginning  of  the  atrophy 
in  these  cases  was  not  always  the  same.  In  two  instances  it  began  by 
pallor ;  in  the  others  by  red  spots,  next  followed  by  loss  of  color ;  and 
finally  there  was  a  parchment-like  appearance  of  the  skin.  Sensibility 
was  not  lowered  in  any  instance,  but  in  two  there  was  itching,  as  in  Dra- 
per's case.  In  one  the  disease  was  preceded  by  spasms  of  the  masseter 
muscles ;  in  six  the  tongue  was  atrophied  ;  in  one  the  tonsil ;  and  in  the 
rest  the  soft  palate.  In  two  cases  there  was  deafness.  In  no  case  was 
there  affection  of  the  secretion  of  saliva  ;  but  in  one  there  was  diminished 
pulsation  in  the  carotid  of  the  affected  side.  In  none  were  there  indica- 
tions of  central  disease.  The  cutaneous  changes  alluded  to  are  peculiar, 
and  a  variety  of  trophic  alterations  may  attend  the  disease  ;  such,  for  in- 
stance, as  falling  out  of  the  hair,  or  changes  in  color  and  the  appearance 
of  eczema.  The  sweat-glands  do  not  seem  to  be  involved,  but  the  seba- 
ceous secretion  disappears  upon  the  affected  side.  The  atrophy  is  some- 
times quite  extensive,  involving  the  bones,  which,  in  some  cases,  have 


310  DISEASES    OP    THE    SPINAL    CORD. 

been  measured  and  found  to  be  greatly  reduced  in  size.  Electric  contrac- 
tility of  the  muscles  does  not  appear  to  be  in  the  least  diminished.  The 
temperature  of  the  affected  side  is  generally  lowered,  but  there  is  no  di- 
minution of  sensibility.  The  left  side  appears  to  be  the  more  common  seat 
of  the  disease,  and  of  the  twelve  cases  already  alluded  to,  but  one  was  of 
the  right  half  of  the  face. 

Causes. — In  some  of  the  reported  cases  there  was  a  history  of  pre- 
vious intermittent  fever,  scarlatina  (Hueter  refers  to  whooping-cough  as 
having  had  something  to  do  with  the  genesis  of  this  disease),  and  scrofula, 
and  in  one  case  there  was  a  fall  upon  the  head,  but  it  is  a  question  of 
great  doubt  whether  these  were  concerned  in  the  development  of  the  atro- 
phic condition.  Courtet  reports  a  case  of  right-sided  facial  atrophy  in  a 
subject  who  had  been  delivered  with  forceps.  In  this  case  the  right  pupil 
was  the  largest,  which  suggests  the  fact  that  there  may  have  been  some 
intracranial  lesion.  It  seems,  however,  to  be  a  disease  which  is  more 
common  between  the  tenth  and  the  thirtieth  year,  and  women  are  more 
often  affected  than  men. 

Pathology. — Undoubtedly  this  disorder  is  one  of  a  trophic  nature, 
and  of  central  origin.  The  absence  of  motorial  or  sensorial  disturbances 
makes  this  theory  very  plausible.  If  the  lesion  were  of  a  peripheral  char- 
acter, it  is  highly  probable  that  both  sensation  and  motion  would  be  af- 
fected, for  I  cannot  conceive  a  diseased  condition  of  trophic  filaments 
alone  when  they  are  found  in  company  with  other  sensor  and  motor  fila- 
ments, as  in  a  nerve-trunk  which  is  diseased.  This  hypothesis  seems  more 
reasonable  when  it  is  borne  in  mind  that  the  parts  atrophied  are  supplied 
by  other  cranial  nerves  than  the  seventh.  I  therefore  think  that  the  the- 
ory of  degeneration  of  the  trophic  cells  of  the  bulb  is  a  much  more  ac- 
ceptable one  than  that  held  by  Bergson  and  others.  Eulenburg  considers 
it  to  be  essentially  a  lesion  of  the  fifth  pair,  in  which  opinion  he  is  sus- 
tained by  Romberg,  Samuels,  Charcot,  and  Vulpian.  Against  this  it 
may  be  urged  that  lesions  of  the  fifth  nerve  of  a  trophic  nature  are  gene- 
rally followed  by  corneal  changes,  which,  so  far  as  I  can  learn,  have  never 
been  witnessed  in  this  disorder.  Brunner  is  of  the  opinion  that  the  con- 
dition is  connected  with  a  continued  irritation  of  the  cervical  sympathetic 
upon  the  affected  side. 

Diagnosis. — Progressive  muscular  atrophy  and  facial  paralysis  seem 
to  be  the  only  diseases  with  which  this  may  be  confounded.  Against 
the  first  it  may  be  said  that  there  are  never  the  peculiar  cutaneous 
changes  of  the  disease  under  discussion — no  dark  spots,  no  falling  out  of 
the  hair,  no  tightness  of  the  skin;  and  moreover,  this  site  of  atrophy  is 
very  rare  in  progressive  muscular  atrophy.  Facial  paralysis  is  nearly 
always  of  sudden  appearance,  and  the  muscles  lose  their  electric  con- 
tractility. 

Prognosis. — As  far  as  I  can  learn  no  deaths  have  been  reported,  and 
no  cures  by  drugs.  From  its  progressive  nature  (and  particularly  if  we 
concede  it  to  be  a  central  disease  of  a  degenerative  character)  the  prog- 
nosis must  be  bad,  though  two  or  three  cases  have  been  related,  however, 


PSEUDO-HYPERTROPHIC    MUSCULAR    PARALYSIS.         311 

in  which  there  was  an  arrest  of  the  atrophy  without  any  treatment.     In 
Belot's^  case  the  disease  became  stationary  after  a  year. 

Treatment. — Electricity  is  indicated,  but  its  use  has  only  once  been 
attended  by  slight  improvement  in  the  hands  of  Moore,^  who  reported  a 
case  which  was  benefited. 

PSEUDO-HYPERTROPHIC  MUSCULAR  PARALYSIS. 

Synonyms. — Myosclerotic  paralysis ;  sclerose  musculaire  progressive 
(Requin) ;  myosclerosis.     Lipomatosis  musculorum  luxurians  (Heller). 

Definition. — A  disease  of  infancy,  expressed  by  increase  of  volume 
and  hardness  of  certain  muscles  usually  of  the  lower  extremities,  such  in- 
crease being  due  to  fatty  substitution;  by  secondary  atrophy  and  paresis 
and  by  conservation  of  cutaneous  sensibility  and  the  functions  of  the  bow- 
els and  bladder. 

Though  first  described  by  Sir  Chas.  BelP  in  1830,  by  two  Italians,  Coste  * 
and  Gioja  in  1838,  and  subsequently  by  Meryon''  in  1852,  it  was  not  un- 
til 1868  that  the  disease  received  much  attention,  when  Duchenne® 
presented  his  collection  of  thirteen  cases,  with  a  critical  analysis.  At 
about  the  same  time  Meredith  Clymer'  was  the  first  in  this  country  to 
describe  the  condition.  After  him,  Ingall  and  Webber,*  Pepper,'^  Weir 
Mitchell,^"  and  others,  and  among  them  Poore,"  of  New  York,  has  fully 
discussed  the  subject,  while  numerous  continental  writers  have  published 
cases. 

Of  late,  Gowers  ^^  has  embodied  his  carefully  made  and  valuable  ob- 
servations in  a  well  written  volume  in  which  the  history  of  the  disease  is 
illustrated  by  brief  reference  to  the  cases  reported  by  Continental,  Eng- 
lish and  American  authorities,  one  hundred  and  seventy-six  in  number. 
Of  these,  all  but  eight  were  among  children. 

Symptoms — Duchenne  details  the  symptoms  in  the  following  order : 
1.  In  the  beginning,  feebleness  of  the  lower  limbs.  2,  Lateral  balancing 
of  the  trunk  and  widening  of  the  legs  during  walking.  3.  A  peculiar 
curvature  of  the  spine  or  saddle-back,  both  in  walking  and  standing. 
4.  Talipes  equinus,  with  an  over  extension  of  the  first  phalanges  of  the 
toes.  5.  Apparent  muscular  hypertrophy.  6.  Stationary  condition. 
7.  Generalization  and  aggravation  of  the  paralysis.  These  are  the  strik- 
ing features  of  the  disease,  which  is  far  from   common, — and,  so  far  I 

^  Quoted  by  Draper,  Am.  Psy.  Journal,  Feb.,  1876.  ^  Op.  cit. 

3]Srervous  System  of  the  Human  Body,  etc.,  2d  Ed.,  1830,  3d  Ed.,  1836. 

*Eeferred  to  in  Schmidt's  Jahrbuch,  xxiv.,  p.  176  and  by  Gowers. 

»  Transaction  of  Medico  Chirurgical  Soc,  xxxv.,  1852. 

6  Archives  General  de  Med.,  January,  1868,  and  following  numbers. 

^  Appendix  to  Aitkin's  Practice  of  Medicine,  1868. 

8  Boston  Medical  and  Surgical  Journal,  Nov.,  1878. 

'Philadelphia  Medical  Times,  June  and  July,  1871. 

10  Photographic  Review,  Oct.,  1871. 

11  New  York  MedicalJournal,  June,  1875. 

12  Pseudo-Hypertrophic  Muscular  Paralysis,  a  clinical  lecture,  London,  1879. 


312  d'iseases  of  the  spinal  cokd. 

have  seeu  less  than  a  dozen  cases.  In  illustration  of  the  development 
of  the  disease,  I  may  present  the  history  of  a  well-marked  case  which  I 
was  permitted  to  examine  by  Dr.  V.  P.  Gibney. 

F.  S.  M.,  aged  13.  Previous  health  excellent,  her  only  illnesses  being 
whooping-cough  at  the  age  of  9  months,  and  scarlatina  one  year  ago, 
which  was  followed  by  some  otitis.  Her  family  history  is  good,  so  far  as 
nervous  disease  is  concerned.  Her  father  died  of  phthisis,  and  her  mother 
is  alive  and  healthy.  Her  ancestors  were  long-lived  people.  She  tells  us 
of  an  injury  received  in  1870,  a  boy  having  thrown  a  brick  at  her,  which 
struck  her  in  the  small  of  the  back.  No  fever  or  pain  preceded  her 
present  trouble-  Her  disease  was  of  gradual  development,  and  the  hyper- 
trophy followed  the  injury  which  has  just  been  alluded  to.  At  the  end  of 
six  months  she  found  it  difficult  to  go  up  stairs,  and  her  helplessness  in- 
creased until  the  time  of  admission  into  the  Hospital  for  Ruptured  and 
Crippled,  April  7,  1876.  The  following  history  was  then  taken:  Com- 
plexion, light ;  hair,  brown  ;  eyes,  hazel.  She  is  small  for  her  age,  though 
well  developed.  She  stands  with  abdomen  prominent,  chest  and  head 
thrown  backwards ;  walks  with  an  unsteady,  waddling  gait.  Upper  ex- 
tremities, with  exception  of  elbow-joints,  which  permit  extension  beyond 
an  angle  of  180°,  normal.  From  the  sixth  dorsal  to  the  sacrum  there  is 
a  lordosis  of  three  inches,  the  point  of  greatest  incurvation  being  at  the 
third  lumbar  vertebra.  There  is  tenderness  on  deep  pressure  over  the 
twelfth  dorsal  vertebra,  while  both  trochanters  stand  out  prominently,  and 
the  limbs  are  widely  separated,  and  there  seems  to  be  no  trouble  about  the 
hip-joints.  There  is  marked  diminution  in  power  of  the  extensors  of  the 
legs,  preventing  her  from  holding  the  limb  at  a  right  angle  to  the  body. 
There  is  no  marked  loss  of  power  in  the  flexors.  But  there  seems  to  be 
some  loss  of  power  in  the  anterior  foot  muscles ;  no  comparative  atrophy 
of  limbs.  The  muscles  of  the  back  seem  small  and  poorly  nourished. 
The  girl  has  difficulty  in  arising  from,  or  assuming  the  sitting  posture. 
The  lordosis  can  be  overcome  by  the  voluntary  act  of  stooping  forward. 

Treatment. — Spinal  brace  and  electricity. 

Through  the  kindness  of  Dr.  Gibney,  I  was  permitted  to  examine 
the  patient,  whom  I  found  to  be  a  rather  well-nourished  girl.  I  was 
immediately  struck  by  her  gait,  which  was  characteristic  of  pseudo- 
hypertrophic paralysis.  The  feet  were  planted  widely  apart,  and  when 
propulsion  was  attempted,  the  whole  pelvis  was  seemingly  twisted,  and 
the  legs  clumsily  swung  forward.  The  body  swayed  from  side  to  side,  the 
abdomen  was  prominent,  and  the  shoulders  drawn  back,  so  that  the  ex- 
treme lordosis  described  so  clearly  by  Duchenne  was  very  beautifully 
shown.  When  stripped,  this  exaggerated  curve  was  found  to  be  very 
great.  A  plumb  line  held  at  the  seventh  cervical  spine  fell  about  four 
inches  back  of  a  line  drawn, across  the  upper  edge  of  the  sacrum.  When 
my  hand  was  placed  upon  her  abdomen,  and  an  attempt  was  made  to 
force  her  to  stand  erect,  the  nates  were  immediately  thrown  backwards, 
and  she  would  have  pitched  forward  if  not  supported.  When  she  at- 
tempted to  walk,  the  pelvis  seemed  to  be  lifted  on  the  side  of  the  limb 
which  was  raised,  and  at  the  same  time  the  corresponding  side  of  the  ab- 
domen became  quite  flat.  Her  gait  was  waddling,  and  she  progressed 
very  slowly.  There  was  some  spinal  tenderness,  but  no  other  disturbance 
of  sensibility  either  in  the  sound  or  hypertrophied  muscles.  The  latter 
were  those  of  the  back  of  the  leg,  which  were  much  larger  on  both  sides 


PSEUDO  hypeet|rophic^  muscular  paralysis.       313 

than  they  should  have  been,  and  were  quite  hard  and  in  marked  contrast 
to  the  other  muscles  of  the  body,  which  were  flabby  and  poorly  nourished. 
The  muscles  of  both  thighs  at  the  inner  side  seemed  to  be  atrophied,  as 
were  all  the  muscles  of  the  back  ;  but  the  arms  were  of  normal  contour, 
and  apparently  unaffected.  There  was  considerable  loss  of  power  in  the 
lower  extremities,  the  patient  being  unable  without  great  effort  to  rise 
from  her  chair,  and  when  she  attempted  to  do  so,  she  planted  her  feet 
widely  apart  and  approximated  her  knees.  The  color  of  the  skin  was 
rather  darker  than  it  should  be,  and  especially  on  the  feet,  legs,  and  hy- 
pertrophied  calves,  was  there  mottling  and  imperfect  incubation.  No 
difference  in  tactile  sensibility  could  be  noted.  Measurements  of  different 
parts  gave  the  following  results  : — 

About  shoulders 29  inches. 

About  waist 24  " 

Middle  of  right  thigh 14  " 

Middle  of  left  thigh 13J  " 

Eight  thigh,  just  above  knee 11  " 

Left  thigh,  just  above  knee 12  " 

Eight  calf 12  " 

Left  calf 12  " 

A  case  reported  to  me  by  my  friend  Dr.  G.  H.  Swazey  is  the  following. 
This  patient  was  also  seen  by  Dr.  J.  Lewis  Smith : — 

J.  D.,  aged  2  years  8  months.  Has  always  been  a  healthy  boy  until 
four  weeks  ago,  when  it  was  noticed  that  he  seemed  weak  in  his  legs, 
especially  in  the  morning,  or  after  sitting  awhile.  Has  not  complained 
of  any  pain.  When  the  child  walks,  it  is  in  a  peculiar  wabbling  sort  of 
a  way,  with  his  legs  wide  apart,  and  his  shoulders  carried  well  back.  He 
cannot  stand  well  with  his  legs  close  together,  but  soon  totters  and  falls. 
After  he  has  walked  awhile  this  peculiarity  of  gait  is  not  so  perceptible. 
The  left  leg  measures  around  the  calf  eight  and  one-eighth  inches,  right 
leg  around  the  calf  eight  inches.  Just  above  the  knee  left  leg  measures 
nine  and  a  quarter  inches ;  right  leg,  same  place,  nine  and  one-eighth 
inches. 

The  weakness  in  the  legs  has  been  steadily  increasing  from  the  first. 
The  grandmother  of  the  child  on  the  maternal  side  has  epilepsy ;  and  the 
grandmother  on  the  father's  side  has  what  the  mother  calls  weak  spells, 
apparently  of  an  epileptic  character.  An  aunt  and  uncle  on  the  father's 
side  have  epilepsy,  and  there  is  also  a  history  of  syphilis  in  the  family. 
The  mother  has  had  miscarriages,  apparently  due  to  that  cause.  The  father 
has  had  eruptions  and  other  symptoms.  March  28th  commenced  treat- 
ment with  the  faradic  current  to  the  muscles,  which  was  continued  three 
times  a  week  for  six  weeks ;  the  disease  slowly  progressing.  At  this  time 
the  patient  left  off  coming,  and  has  not  since  been  seen. 

Weakness  of  the  lower  extremities  is  one  of  the  earliest  symptoms,  and 
is  gradual  in  its  appearance,  and  not  preceded  by  fever,  as  is  generally 
the  case  in  infantile  spinal  paralysis.  This  impairment  of  power  may 
begin  imperceptibly,  and  first  attract  the  attention  of  the  parent  by  the 
inability  of  the  child  to  walk  at  the  usual  time,  or  may  appear  subsequently, 
the  child  falling  frequently  or  moving  clumsily.  In  Poore's  collection  of 
85  cases,  it  is  shown  that  "  3  never  walked  at  all,  24  never  walked  well, 


314  DISEASES    OF    THE    SPINAL    CORD. 

1  is  reported  as  coming  on  gradually,  52  walked  well  at  first,  and  in  5 
eases  no  mention  is  made  of  the  period  of  walking."  "  Of  those  who  walked 
well,  2  began  to  walk  at  eighteen  months,  3  at  two  years,  3  at  two-and-a- 
half  years,  4  at  four  years,  1  at  five,  and  5  are  reported  as  walking  late 
and  badly." 

Fig.  47. 


(Gowers)  Pseudo-Hyperirophic  Paralysis. 

Duchenne  and  Drake  reported  cases  in  which  convulsions  were  the 
beginning  of  the  disease.  Pain  in  the  calves  of  the  legs  or  back  is  some- 
times the  first  symptom,  but  is  by  no  means  one  to  expect  as  a  rule.  The 
appearance  of  the  patient  is  most  striking.  The  belly  seems  to  be  thrown 
out,  the  lumbar  curve  is  increased,  and  the  feet  are  widely  separated. 
When  the  child  attempts  to  walk,  his  movements  are  very  much  like  those 
which  we  might  expect  to  see  in  an  individual  laboring  through  a  quag- 
mire. There  is  a  certain  amount  of  waddling,  the  legs  being  separated, 
and  the  feet  planted  at  some  distance  apart.  In  progression  the  body  is 
inclined  to  the  side  on  which  the  foot  is  planted,  and  there  is  some  jerk 
made  in  the  effort  to  carry  the  foot  forward.  The  patient  rises  from 
the  sitting  posture  with  some  difficulty,  as  there  is  great  impairment  of 
the  extensor  muscles  of  the  spine.  This  weakness  is  the  cause  of 
the  difficulty  in  keeping  his  balance.  The  next  stage  of  the  disease  is 
the  development  of  the  hypertrophy.  Very  often  this  change  is  an 
early  one,  and  may  follow  closely  after  the  commencement  of  the  impaired 
motor  power.     The  calves  are  generally  first  enlarged,  and  this  enlarge- 


PSEUDO    HYPERTROPHIC    MUSCULAR    PARALYSIS.         315 

ment  may  begin  with  the  difficulty  in  walking,  or  within  a  period  any- 
where from  six  months  to  several  years  after  the  beginning  of  the  disease. 
This  enlargement  is  not,  however,  always  confined  to  the  calves,  but  may 
affect  the  other  muscles  of  the  lower  extremities,  or  even  those  of  the 
upper.  The  glutei,  gastrocnemii,  deltoid,  and  many  other  muscles  have 
been  involved  in  cases  reported  by  different  observers.  When  the  mus- 
cles are  contracted,  they  stand  out  quite  prominent,  and  in  one  of  the 
cases  reported  by  Barlow^  the  child's  appearance  resembled  that  of  the 
Farnese  Hercules.  The  child  is  unwieldy  and  awkward,  and  though 
there  is  at  this  stage  some  increase  in  strength  of  some  of  the  members 
used  in  locomotion,  the  child  does  not  seem  to  have  very  much  motor 
power,  for  he  can  scarcely  walk.  The  muscles  not  hypertrophied  may 
undergo  an  atrophic  change,  greatly  adding  to  the  deformity.  In  regard 
to  the  talipes  that  may  be  produced,  the  extensors  are  agitated  by  spas- 
modic contractions,  which  become  more  aggravated  as  the  attempt  to 
walk  is  persisted  in,  so  that,  after  a  few  steps,  the  child  is  quite  likely  to 
fall.  Dr.  Gowers  has  devoted  much  time  to  the  discussion  of  the  sub- 
ject of  muscular  enfeeblement  as  a  symptom.'^  He  alludes  to  certain  pe- 
culiarities of  the  patient's  behaviour,  which  are  striking  and  pathognomo- 
nic. One  of  these  is  the  manner  in  which  the  patient  arises  from  the 
floor.  Owing  to  the  weakness  of  the  muscles  of  the  back,  the  little  pa- 
tient always  places  his  hands  on  his  knees,  "  apparently  to  push  the  trunk 
up,  to  help  the  extension  of  the  hip-joint."  This,  Gowers  says,  is  met  with 
in  no  other  affection,  and  I  am  inclined  to  agree  with  him. 

He  first  places  his  hand  on  the  knee-joint,  and  when  the  knees  are  ex- 
tended he  works  his  way  up,  putting  his  hand  upon  his  trunk  until  he 
effects  extension  of  the  hip. 

"  The  reason  why  this  action  affords  such  help  in  extension  of  the 
knees,  says  Gowers,  is  obvious  on  a  little  consideration.  In  rising  from 
the  ground  with  the  knees  flexed,  the  weight  of  the  trunk,  resting  on  the 
hip-joint,  is  at  the  extremity  (Fig.  48,  W.)  of  a  lever  (the  femur)  of  the 
third  order,  the  fulcrum  (F)  being  at  the  knee,  and  the  power,  the  con- 
traction of  the  quadriceps  extensor,  being  applied  (P)  between  the  weight 
and  the  fulcrum, — i.  e.,  in  the  position  in  which  it  acts  to  least  advantage. 
But  by  placing  the  hands  on  the  knees, — i.  e.,  on  the  end  of  the  femur, — a 
large  part  of  the  weight  (the  larger  the  more  the  patient  bends  forward) 
is  transferred  to  the  lever  (at  W)  close  to  the  fulcrum ;  the  lever  is,  in  so  far, 
transformed  into  one  of  the  second  order,  in  which  the  weight  is  between 


1  Op.  cit.,  p.  11. 

^  Even  so  far  back  as  1830  Sir  Charles  Bell*  recognized  this  as  a  striking  symptom. 
"  The  paralytic  debility  of  the  muscles  came  on  gradually  :  he  was  first  sensible  of  it 
at  a  public  school,  about  eight  years  ago.  It  began  with  a  weakness  in  the  thighs, 
which  disabled  him  from  rising ;  and  it  is  now  curious  to  observe  how  he  will  twist  and 
jerk  his  body  to  throw  himself  upright  from  his  seat.  I  use  this  expression,  for  it  is  a 
different  motion  from  that  of  rising  from  the  chair." 

*  Op.  Cit.  Third  Edition,  p.  432,  case  clxxx. 


316  DISEASES    OF    THE    SPINAL    CORD. 

the  power  and  the  fulcrum,  and  the  power  is  economized  in  the  greatest  de- 
gree. Moreover,  if  the  patient  bend  down,  the  centre  of  gravity  may- 
even  be  carried  in  front  of  the  knees,  and  then,  if  the  hands  grasp  the  knees 
firmly,  the  weight  of  the  body,  instead  of  being  the  weight  to  be  moved, 
becomes  a  force  applied  to  the  upper  end  of  the  femur,  effecting  the 
extension  of  the  knee  without  the  slightest  action  of  the  quadriceps  ex- 

Fi<r.  48. 


tensor,  as  any  one  may  ascertain  by  observing  the  mobility  of  the  j^atella 
in  this  attitude."  The  skin  may  often  be  greatly  discolored  in  patches 
just  as  it  is  in  infantile  paralysis,  and  Duchenne  has  called  attention  to 
this  mottling,  which  is  due  to  modified  cutaneous  circulation,  and  is  seen 
especially  during  the  later  stages  of  the  disease.  It  is  more  often  con- 
fined to  the  lower  extremities,  and  the  patches  which  at  first  appear  as 
bright  red  discolorations  gradually  become  more  dusky  as  they  are  ex- 
posed to  the  air.  This  mottling  is  increased  by  muscular  action,  and  in 
certain  regions  was  found  by  Benedikt  to  be  connected  with  local  sweat- 
ing. The  temperature  of  the  hypertrophied  muscles  is  higher  by  a  de- 
gree or  two  than  those  that  are  atrophied  ;  and  in  the  earlier  stages  elec- 
tric contractility  is  rarely  affected,  but  in  the  later  it  is  greatly  dimin- 
ished. Of  course  this  depends  upon  the  fatty  substitution  which  the 
muscular  tissue  has  undergone,  for  but  a  small  amount  of  normal  muscu- 
lar fibre  remains  to  be  called  into  action  by  the  electric  stimulus.  Put- 
nam, of  Boston  ^  reports  a  case  of  pseudo-hypertrophic  paralysis  with  in- 
volvement of  the  tongue,  which  was  broad  and  thick,  and  the  face  was 
smaller  than  it  should  have  been.  These  conditions  existed  in  addition 
to  hypertrophy  of  the  legs  and  thighs,  back  and  arms — it  is  rare,  how- 
ever, to  find  involvement  of  the  face. 

^  Bost.  Med.  and  Surg.  Journal,  Jan.  3,  1880. 


PSEUDO-HYPERTROPHIC    MUSCULAR    PARALYSIS.         317 

Gowers  ^  presents  some  cases  of  the  disease  in  adults.  The  examples 
of  lipomatous  myo-atrophy,  given  by  him,  are  seven  in  number.  In  all 
the  disease  began  after  twenty,  and  in  several  after  forty  or  thereabouts — 
two  being  females.  In  two  cases,  those  reported  by  Barth  and  Miiller 
there  were  autopsies  made,  — evidences  of  lateral  sclerosis  were  found, 
and  degenerative  changes  in  the  ganglion  cells  of  the  anterior  cornua 
were  disclosed.  The  lower  extremities  were  affected  in  all  the  cases, 
though  in  several  the  hypertrophy  was  found  in  the  upper  as  well.  In 
three  cases  there  was  mental  derangement. 

Causes. — Beyond  the  question  of  heredity  it  is  impossible  to  go  in 
our  search  for  causes.  One  or  two  cases,  however,  are  mentioned  by 
foreign  observers  in  which  injury  preceded  the  disease.  Kesteven "  re- 
ported one  of  these,  and  in  this  case  the  hypertrophy  appeared  at  the 
fifteenth  year. 

Poore's  table  ^  includes  the  following  examples  of  heredity  : — 

"  In  two  cases  a  maternal  uncle  and  aunt  had  this  disease. 

"In  one  case  three  maternal  uncles  and  aunts  had  this  disease. 

"  In  one  case  one  maternal  uncle  and  one  half-uncle  had  this  disease. 

"  In  one  case  three  maternal  half-brothers  had  this  disease. 

"  In  one  case  a  maternal  half-brother,  three  maternal  uncles,  and  other 
members  on  the  mother's  side,  had  shown  the  symptoms  of  pseudo-hyper- 
trophic  paralysis. 

"  In  thirty-seven  instances,  two  or  more  belonged  to  the  same  family. 
It  will  be  observed  that  it  is  only  on  the  mother's  side  that  this  hereditary 
influence  is  transmitted  ;  while  the  disease  shows  itself  almost  exclusively 
in  the  males ;  thus  in  a  case  reported  by  Duchenne,  the  mother,  while 
she  escaped,  transmitted  the  disease  to  the  children  of  her  marriage. 
The  same  fact  is  stated  in  Foster's  case. 

"  In  one  case  a  maternal  grandfather  was  hemiplegic. 

"  In  one  case  a  paternal  grandfather  was  insane. 

"  In  one  case  a  father  was  insane. 

"  In  one  case  a  father  was  intemperate. 

"  In  one  case  two  brothers  died  of  granular  meningitis. 

"  In  one  case  a  brother  was  an  idiot. 

*'  In  fifteen  cases  of  the  eighty-five  the  family  history  was  good. 

"  In  thirty -three  cases  no  mention  of  family  history  is  made." 

Like  other  spinal  troubles  it  is  found  that  several  members  of  the 
same  family  may  be  afilicted. 

Drs.  Steele  and  Kingsley  *  of  St.  Louis  have  reported  several  cases  of 
pseudo-hypertrophic  paralysis.  Dr.  Steele's  cases  were  two  brothers,  and 
Dr.  Kingsley's  two  sisters,  aged  ten  and  thirteen  years.  I  have  seen  two 
cases  in  the  same  family,  both  of  whom  were  girls,  one  being  ten  years 
old,  the  other  seventeen.     The  youngest  girl  presented  the  lumbar  curve 

1  Op.  Cit.,  p.  62. 

^Journal  of  Mental  Science,  vol.  xvi.,  April,  1871,  p.  48. 

'  Loc.  cit. 

*  Reported  in  ''  Alienist  and  Neurologist,"  Jan.,  1880. 


318  DISEASES    OF    THE    SPINAL    CORD. 

and  arose  from  her  chair  with  difficulty.  Her  thighs  were  firm,  but 
smaller  than  they  should  be,  but  the  calves  and  nates  were  hyper- 
trophied  and  hard,  and  it  was  impossible  to  take  up  any  considerable 
amount  of  tissue  between  the  fingers.  She  arose  with  difficulty  from  her 
chair.  The  older  sister  was  helpless  and  could  neither  walk  or  stand, 
and  in  her  case  the  disease  had  begun  about  the  third  year.  I  have  also 
been  informed  of  a  family  in  which  five  children  are  affected. 

Pathology  and  Morbid  Anatomy. — According  to  Barlow,  the 
first  examination  of  muscular  tissue  in  pseudohypertrophic  paralysis  was 
made  by  Griesinger  and  Billroth  in  1865.  Griesinger  excised  a  small 
portion  of  the  left  deltoid,  which  was  hypertrophied  and  paralyzed, 
and  microscopically  examined  the  muscle,  which  resembled  adipose 
tissue.  He  found  the  fasciculi  in  a  perfect  state,  but  surrounded  by  fat. 
Euleuburg^  and  Conheim''  found  the  muscular  fibres  reduced  to  fully  one- 
sixth  their  normal  size,  and  in  some  localities  there  were  masses  which 
they  supposed  were  the  sheaths  of  empty  sarcolemmse. 

Auerbach^  found  hypertrophy  of  the  muscular  fibres,  and  an  increased 
development  of  nuclei,  but  no  interstitial  fat  deposit ;  but  this  was  in  a 
patient  who  died  during  the  early  stages  of  the  disease.  Berger's*  expe- 
rience was  identical  in  an  early  case.  Charcot"  examined  a  case  (that 
seen  by  Berger),  and  found  the  psoas  in  a  state  of  primary  alteratien. 
The  primitive  muscular  bundles  were  separated  by  broad  spaces  of  con- 
nective tissue  containing  cells  of  a  spindle  shape,  and  nuclei.  Other 
muscles  were  likevvise  afl^ected.  The  pectoral  muscles,  and  those  having 
a  sacro-lumbar  attachment,  containing  fewer  nuclei,  and  the  internuclear 
spaces  were  filled  with  wavy  connective  tissue.  In  muscles  which  had 
undergone  still  more  advanced  degeneration,  there  was  some  evidence 
of  fatty  deposit.  In  this  case  he  witnessed  three  stages  of  degeneration. 
In  the  earliest  there  was  atrophy  of  muscular  bundles,  indistinct  longitu- 
dinal stride,  and  sometimes  transverse  striie.  The  sarcolemmse  were  filled 
with  a  hyaline  substance. 

Duchenne"  denies  the  existence  of  empty  sarcolemmse,  and  regards  the 
enlargement  due  to  an  increase  of  connective  tissue  containing  fat-cells. 
Dr.  Gowers  has  made  an  autopsy  which  revealed  a  condition  of  afl^airs 
strikingly  like  that  found  by  Charcot.  The  gastrocnemius  muscle  resem- 
bled a  fatty  tumor,  "  a  yellow,  greasy  mass  of  fat,  in  which  no  trace  of 
muscular  redness  could  be  perceived  "  The  muscular  fibres  preented  no 
granular  degeneration,  but  ran  through  masses  of  fat-cells  with  more  or 
less  fibrous  tissue  intervening.  In  the  "  narrow  fibres  the  transverse  striae 
were  farther  apart  than  in  the  wider  fibres."     Various  observers  have 


1  Archiv  fiir  Heilkunde,  1865. 

■^  Verliandlung  der  Berliner  Med.  Ges.  i.,  pp.  101-205. 

^  Virchow,  Archiv.,  vol.  iii.  p.  224. 

*  Deutsche  Archiv  fur  Klin.  Med.,  1872,  p.  303. 

»  Archives  de  Physiol.,  etc.,  1872,  p.  1. 

®  De  relectrisation  localisee,  Paris,  1872,  3d  edition,  p.  604. 


PSEUDO     HYPERTROPHIC    MUSCULAR    PARALYSIS.         319 

examined  the  cord  without  finding  any  characteristic  sign  of  trouble 
The  motor-cells  have  as  a  rule  been  enlarged.  Gowers  rather  adopts  the 
view  that  pseudo-hypertrophic  paralysis  is  primarily  of  peripheral  origin, 
and  refers  to  the  observations  of  Tschirjew,  \vho  found  that  the  sensory 
nerve  fibres  end  in  the  interstitial  fibrous  tissue,  and  that  the  posterior 
nerve-roots  were  those  generally  affected  in  this  disease.  He  therefore 
traces  some  connection  between  these  facts,  especially  as  the  fibrous  tissue 
is  the  primary  seat  of  the  changes.  He  holds  that  there  is  an  ascending 
degeneration. 


Appearance  of  Muscular  Tissue.    (Charcot.) 

Hitzig  found  an  extraordinary  increase  in  size  of  the  arm  of  an  adult, 
after  injury  near  the  shoulder  joint,  and  the  changed  condition  of  the 
muscle  was  in  every  way  like  that  of  pseudo-hypertrophic  paralysis. 

In  this  case  it  was  possible  that  there  was  an  ascending  neuritis,  but  it  is 
also  possible  that  the  cerebro-spinal  influence  upon  nutrition  was  suspend- 
ed, while  sympathetic  system  exerted  an  influence  which  gave  rise  to  an 
increase  in  fat  deposit.  The  effect  of  certain  kinds  of  injury  or  irritation 
is  witnessed  in  various  pathological  processes,  which  are  characterized  by 
the  rapid  formation  of  new  tissue  or  phenomena  of  nutrition.  The  exist- 
ence of  hypertrophy  and  atrophy,  at  different  stages  of  the  same  process, 
seems  to  me  to  be,  in  one  instance,  the  commencing  peripheral  lesion,  and 
in  the  other  the  result  of  a  consecutive  cerebral  change. 

Diagnosis. — Progressive  muscular  atrophy  seems  to  be  the  only  dis- 
ease with  which  this  condition  may  be  mistaken.  If  the  patient  is  seen 
at  a  time  when  the  conditions  of  atrophy  and  hypertrophy  coexist,  it  is 
not  always  easy  to  tell  whether  there  is  an  increase  of  volume,  or  simply 
an  atrophic  condition  of  some  muscles^  while  others  are  of  normal  size ; 
but  the  other  symptoms,  alluded  to,  the  exaggerated  lumbar  curve,  and 
the  waddling  walk,  should  settle  the  question  of  diagnosis.  Progressive 
muscular  atrophy  is  also  generally  a  disease  which  rarely  appears  at  so 
early  a  period  as  does  pseudo-hypertrophic  paralysis.     Increase  of  size 


320  DISEASES   OF    THE    SPINAL    CORD. 

from  determination  of  blood  to  a  muscle,  such  as  that  reported  by  Maun- 
der/ and  sometimes  fatty  development,  without  paralytic  symptoms,  may 
deceive  the  incautious. 

Prognosis. — The  disease  is  slowly  progressive,  and  death  occurs 
generally  from  some  other  disease.  Poore  reports  thirteen  deaths. 
Phthisis,  pleuro-pneumouia,  uncomplicated  pneumonia,  and  croup  appear 
to  have  carried  oif  most  of  these  cases  ;  and  it  seems  as  if  pulmonary  dis- 
ease bore  some  special  relation  to  organic  disease  of  the  cord,  particularly 
when  trophic  disorder  accompanies  such  disease.  In  several  of  the 
spinal  affections,  especially  when  the  anterior  cornua  are  affected,  there  is 
generally  the  development  of  phthisis  or  other  pulmonary  maladies.  The 
deaths  that  have  been  reported  occurred  rarely  before  the  eighth  year  of 
the  disease,  and  generally  between  the  fourteenth  and  thirtieth. 

Treatment. — Duchenne  reports  two  cures  by  the  faradic  current. 
This  seems  to  be  the  only  remedial  measure  that  promises  anything  very 
encouraging.  In  the  previous  edition  of  this  book  I  advised  the  abolition 
of  fatty  food.  This  I  believe  was  a  mistake,  for  when  we  remember  that 
the  nourishment  of  nervous  tissue  is  more  perfect  when  we  consume  fats 
it  will  be  patent  that  they  are  serviceable.  In  fact  an  enlarged  experience 
teaches  me  that  the  case  will  not  do  so  well  when  fat  does  not  form  a  part 
of  the  dietary.  Massage  should  be  employed  at  least  every  day.  The 
well-known  fact  that  phosphorus  produces  fatty  degeneration  should 
contraindicate  its  use.  Systematic  exercise  with  wooden  dumb  bells,  and 
calisthenics  are  to  be  indulged  in,  and  the  patient  should  be  made  to  walk 
for  a  short  time  every  day.  As  to  mechanical  support  not  much  is  to  be 
said.  Gowers  recommends  Sayre's  jacket,  which  I  think  in  a  few  cases 
is  excellent.  The  children  who  suffer  for  want  of  support  of  the  vertebral 
column  when  the  muscles  of  the  back  are  weakened  may  be  greatly 
helped  by  this  or  some  other  form  of  bodily  sufjport.  Arsenic  and  mer- 
curials have  been  of  service  in  the  hands  of  some  practitioners,  among 
them  Meryon. 

^  Med.  Times  and  Gazette,  March  27,  1862. 


POSTERIOR    SPINAL    SCLEROSIS.  321 


CHAPTER  XT. 

DISEASES  OF  THE  SPINAL  CORD  (Contijtoed.) 
POSTERIOR  SPINAL  SCLEROSIS. 

Synonyms. — Progressive  locomotor  ataxia ;  Tabes  dorsalis;  Ataxie 
locomotrice  progressive;  Locomotor  asynergia,  etc. 

When  disease  of  the  posterior  columns  of  the  cord  exists  we  are  fur- 
nished with  a  very  interesting  and  striking  train  of  symptoms,  which 
are  chiefly  expressed  by  pronounced  disturbance  of  the  locomotory  func- 
tion, diminished  reflex  excitability  and  defects  in  co-ordination  and  sensi- 
bility. So  delicate  has  the  matter  of  diagnosis  become  that  the  coarse 
symptomatology  of  five  or  ten  years  ago  is  not  essential  to  the  recognition 
of  the  aflection.  It  has  been  found  that  cases  of  so  called  "locomotor 
ataxia  "  may  not  be  dependent  upon  disease  of  the  posterior  columns  at  all, 
but  the  symptoms  occur  as  evidence  of  organic  diseases  of  other  parts, 
notably  the  pons.  So,  too,  we  meet  cases  of  disease  of  the  i^osterior  columns 
without  any  of  the  pronounced  locomotory  troubles.  Some  of  these  patients 
are  able  to  stand  with  closed  eyes  and  do  not  walk  with  any  peculiar  stamp. 

Symptoms. — Every  pronounced  case  invariably  presents  three 
marked  symptoms  :  1.  Peculiar  pains  usually  seated  in  the  lower  extremi- 
ties. 2.  A  simple  atrophy  of  the  optic  disk.  3.  An  impairment  of  the 
reflex  function,  usually  found  in  the  tendon  of  the  quadriceps,  or  shown 
in  tardy  action  of  the  pupils.  These  symptoms  are  constant,  but  others 
are  often  found  in  conjunction. 

Most  authors  have  divided  this  disease  into  three  stages :  1.  That 
characterized  by  pains  and  commencing  impairment  of  the  tendon  re- 
flex. 2.  That  marked  by  the  commencement  and  continuance  of  ataxic 
movements,  etc.  3.  The  stage  of  decline  in  which  the  spinal  lesion  usually 
becomes  extended,  and  various  disturbances  of  nutrition  are  conspicuous, 
among  them  bed  sores,  general  wasting  of  tissue,  arthropathies,  intercurrent 
phthisis,  etc.,  etc.  The  first  stage  is  usually  the  longest,  and  may  last 
many  years,  or  it  may  be  almost  inappreciable. 

After  exposure  or  prolonged  dissipation,  the  individual  may  first  notice 
the  commencement  of  the  disease  in  fulgurating  pains  which  dart  from  the 
feet  up  the  legs  and  thighs,  and  for  the  time  he  may  suppose  he  has  simply, 
neuralgia  or  rheumatism.  These  pains  are  worse  at  night,  and  may  be  aggra- 
vated by  damp  or  cold  weather.  They  appear  and  disappear  rapidly,  and 
21 


322  DISEASES    OF   THE   SPINAL   CORD. 

Clarke'  calls  attention  to  their  tendency  to  77ioi'e  suddenly  frrm  one  place 
to  another ;  remaining  in  one  spot  for  some  hours  at  a  time,  and  then 
shifting  to  another.  The  pains  are  so  prominent  a  symptom  that  they 
should  never  be  disregarded.  Some  of  the  most  advanced  English  clini- 
cians go  so  far  as  to  say  that  with  the  presence  of  fulgurating  pains, 
absent  tendon  reflex  and  white  atrophy  of  the  optic  nerves,  they  can  in- 
fallibly diagnose  locomotor  ataxia  even  when  all  other  familiar  symptoms 
are  wanting.  The  pains  are  explosive,  inconstant  and  erratic,  never 
following  the  course  of  any  particular  nerve,  and  there  is  noue  of  the  con- 
stant soreness  or  defined  pain  so  peculiar  to  the  various  forms  of  true 
neuralgia  of  the  lower  extremities.  They  may  shoot  through  the  soles 
of  the  feet,  the  heels,  the  inner  part  of  the  legs,  the  knees,  or  even  the 
thighs.  After  a  time,  which  varies  from  a  few  weeks  to  several  years, 
there  may  be  a  most  disagreeable  sensory  change  of  a  lesser  grade,  which 
is  confined  to  the  feet.  When  walking,  the  patient  complains  that  "  the 
ground  feels  as  if  it  were  covered  with  fur,  or  a  padded  cushion."  Some- 
times the  sensation  is  likened  to  that  produced  by  a  stocking  down  at 
heel,  or  as  if  his  shoe  was  filled  with  sand ;  or,  again,  as  if  he  were  walk- 
ing in  the  air.  There  is  no  loss  of  muscular  power,  nor  general  loss  of 
sensibility,  in  the  preponderance  of  cases  ;  but  there  only  seems  to  be  a 
perversion  of  tactile  sensibility,  and  that  only  limited  to  the  sense  of  pon- 
tact.  By  far  one  of  the  most  interesting  of  the  general  changes  is  the 
absence  of  the  patellar  tendon-reflex.  Enough  has  already  been  said 
about  the  importance  of  this  symptom,  and  it  remains  for  me  to  add  that 
in  the  greater  number  of  cases  it  is  absent,  though  I  do  not  take  the  ex- 
treme view  held  by  many  authorities.  In  a  number  of  instances  I  have 
found  it  exaggerated  instead  of  diminished,  but  I  am  now  inclined  to 
think  that  where  it  is  aggravated  there  is  an  extension  of  the  disease  to 
other  parts  of  the  cord.  In  the  majority  of  cases  of  locomotor  ataxia 
.tkerefore  no  response  follows  the  blow  upon  the  ligamentum  patellte  and 
no  dorsal  clonus  can  be  evoked  by  bending  the  foot.  Heat  and  cold  are 
appreciated,  but  the  shape  or  size  of  the  cold  or  warm  object  cannot  be  per- 
ceived by  the  tactile  sense  alone.  Painful  impressions  are  appreciated, 
but  this  is  all.  Circulation  becomes  sluggish  in  the  limbs,  and  subjec- 
tive cold  is  felt  in  the  lower  extremities.  If  the  individual  is  seated,  and 
the  hand  of  the  examiner  be  held  against  the  sole  of  the  boot  when 
the  thigh  is  flexed,  it  will  be  found  that  he  is  generally  quite  able 
to  extend  the  leg  forcibly,  but  there  may  be  sometimes  a  sli,ht  loss  of 
power  in  subsequent  stages  when  the  anterior  parts  of  the  cord  become 
aflected.  In  the  early  stages  of  what  may  be  called  the  descendinrj 
form,  there,  are  various  ocular  troubles.  Amblyopia,  strabismus, 
or  diplopia  are  among  the  more  common,  and  it  is  not  unusual 
to  find  some  atrophy  of  the  optic  disk  of  either  one  or  both  eyes.  In 
both  forms  of  sclerosis  of  the  cord,  ascending  as  well  as  descending  (these 

1  St.  George's  Hospital  Reports,  1866. 


POSTERIOR    SPINAL    SCLEROSIS.  323 

terms  being  applied  -with  reference  to  the  fact  whether  the  disease  begins  at 
the  upper  part  of  the  cord  or  vice  versa),  it  is  necessary  for  the  patient  to 
look  at  the  objects  which  surround  him  in  order  that  he  may  preserve 
his  equilibrium.  If  he  shuts  his,  eyes,  he  is  apt  to  topple  over ;  and  it  is 
utterly  impossible  for  him  to  walk  in  the  dark  without  holding  on  to 
something  for  support.  The  jDatient  very  often  finds  that  when  he  closes 
his  eyes,  as  he  is  about  to  wash  his  face,  he  is  quite  apt  to  pitch  forward 
against  the  wall.  This  test  is  an  important  one,  and  if  he  is  able  to  stand 
with  his  heels  and  toes  approximated  and  his  eyes  shut,  it  may  be  inferred 
that  either  his  disease  has  not  advanced  to  a  serious  extent,  or  that  it  is 
not  locomotor  ataxia  at  all.  The  early  ocular  trouble  is  strabismus, 
which  is  an  inaugural  symptom,  and  is  very  often  accompanied  by  am- 
blyopia ;  and  if  the  strabismus  be  single,  the  amblyopia  will  be  on  the 
same  side.  The  pupils  are  sluggish,  and  sometimes  are  entirely  insensible 
to  light.  They  are  as  a  rule  both  contracted,  though  they  may  be  une- 
qual. Jackson,  alluding  to  this  state  of  the  pupil,  which  he  calls  "Ar- 
gyle  Robertson's  symptom,"  states  that  he  believes  it  to  be  due  to  a  loss 
of  reflex  activity,  and  but  a  link  in  the  chain  of  disordered  functions, 
which  in  the  lower  extremities  is  expressed  by  the  absent  tendon  reflex. 
In  eight  cases  reported  by  me,  the  tendon  reflex  was  absent  in  four,,  and 
in  two  of  these  subjects  there  was  neither  impairment  of  vision  nor  any 
ocular  troubles  whatever;  but  in  the  other  two  there  were  both  optic 
nerve  atrophy  and  pupillary  changes,  one  woman  having  pin-point  pupils.^ 
Various  paralyses  of  cranial  nerves  may  also  follow,  and  ptosis  is  not  an 
unusual  symptom.  NothnageP  publishes  the  notes  of  a  case  where  hy- 
persesthesia  of  the  parts  supplied  by  the  fifth  nerve  was  a  prominent 
symptom.  The  lost  power  for  localization  is  not  uncommonly  associated 
with  this  disease.  With  closed  eyes,  the  individual  is  unable  to  place  the 
tip  of  his  finger  on  his  nose,  or  upon  any  desired  small  point ;  and,  when 
told  to  touch  the  point  of  a  pin  held  by  an  observer,  he  will  be  unable  to 
do  so,  his  finger  missing  the  mark.  When  awaking,  he  is  often  undecided 
as  to  the  whereabouts  of  his  legs,  or  sometimes  feels  for  a  moment  that 
he  has  none,  and  needs  the  aid  of  vision  to  see  that  there  are  such  mem- 
bers. The  nerve-fibres  in  the  posterior  columns  lose  their  facility  for  the 
conduction  of  sensory  impressions ;  and*  it  is  sometimes  several  seconds 
before  an  impression  made  at  the  periphery  is  received  at  the  sensorium, 
and  appreciated  by  the  individual.  A  symptom  sometimes  found  in  this 
disease,  as  well  as  in  myelitis,  is  the  sense  of  constriction  which  is  referred 
to  the  waist.  The  bowels,  in  the  early  stages,  are  generally  confined ; 
and  there  is  some  loss  of  control  over  the  bladder,  and  constant  de?ire  to 
empty  that  organ.  Romberg  calls  attention  to  the  fact  that  the  stream 
seems  to  have  no  force,  but  falls  to  the  ground  on  leaving  the  meatus. 
The  individual  is  also  troubled  by  erections  during  the  early  stages,  and 


^  Boston  Med.  and  Surgical  Journal,  Dec.  19,  1878. 
2  Berlin  Klin.  Woch.,  xvii.,  1865. 


324  DISEASES    OF    THE    SPINAL    CORD. 

there  is  greatly  increased  sexual  power.  This,  however,  isdiraiuished 
towards  the  end  of  the  disease,  and  in  males  impotence  follows. 

Miiller^  has  noticed  certain  peculiarities  in  regard  to  locomotor  ataxia 
which  have  not  been  fully  noticed  hitherto.  He  speaks  of  the  urethral 
and  rectal  neuralgias,  which  are  connected  with  tenesmus,  and  may  be 
mistaken  for  other  trouble.  He  also  calls  attention  to  the  severe  cough- 
ing paroxysms  that  indicate  affection  of  the  pneumogastric,  and  he  has 
also  found  that  it  is  impossible,  even  by  the  use  of  pilocarpine,  to  induce 
sweating  in  the  affected  limbs. 

Irritability  of  temper,  occasional  mental  disturbance,  and  loss  of  mem- 
ory are  not  rare  evidences  of  intellectual  failure,  and  occur  at  different 
stages.  The  electro-muscular  irritability  seems  to  be  rather  increased 
than  diminished.  The  locomotory  trouble  appears  quite  early,  and  is 
one  of  the  most  distressing  features  of  the  disease.  It  begins  by  an  awk- 
wardness in  progression,  and  the  feet  fly  out  and  are  planted  with  a  kind 
of  jerk,  the  heel  touching  the  ground  first.  The  individual  totters,  and 
is  eventually  unable  to  walk  at  all  without  support,  and  the  gait  cannot 
be  mistaken  by  any  one  who  has  once  witnessed  it.  The  sense  of  appre- 
ciation of  weight  also  seems  to  suffer  to  a  decided  degree.  Jaccoud'' 
found  that  this  is  lost  to  a  great  extent,  and  that  there  is  a  variation  in 
the  power  to  perceive  weights  on  the  two  sides  of  the  body.  In  one  case 
mentioned  by  him,  a  pressure  equal  to  3000  grammes  was  perceived  on 
the  right  side,  and  2800  on  the  left.  The  pains  before  spoken  of  gene- 
rally disappear  as  the  disease  becomes  confirmed,  though  they  may  last 
throughout.  Fibrillary  contractions  are  occasionally  seen  ;  and,  speaking 
of  this,  I  have  often  witnessed  a  curious  phenomenon  which  follows  the 
use  of  faradism.  I  have  noticed  that  when  a  muscle  of  one  leg  was  agi- 
tated by  clonic  contractions,  sometimes  the  same  muscle  in  the  other  leg 
would  be  contracted  synchronously  with  that  -under  electric  stimulation. 
The  patient  is  generally  timid,  and  easily  disconcerted  by  any  sudden 
noise  or  unexpected  excitement ;  and  when  crossing  the  street,  the  desire  to 
avoid  being  run  over  on  the  approach  of  a  wagon  will  produce  such  de- 
moralization as  to  prevent  him  from  taking  another  step,  and  he  some- 
times falls  to  the  ground.  There  is  rarely  trembling,  unless  the  disease 
has  involved  the  upper  part  of  fehe  cord,  when  this  symptom,  as  well  as 
the  inability  to  appreciate  topographical  points,  will  be  marked.  The 
patient  is  generally  worried,  anxious-looking,  and  woe-begone,  and  is  full 
of  complaints.  The  disease  may  last  for  from  five  to  twenty  years,  and 
the  patient  is  carried  off  by  tuberculosis  or  some  intercurrent  pulmonary 
affection.  Atrophy  of  all  the  muscles  of  the  extremities  generally  takes 
place  towards  the  end  of  the  disease,  and  bed-sores  and  arthritic  troubles 
are  annoying  and  painful  forerunners  of  death. 

Charcot  has  called  attention  to  certain  cutaneous  eruptions  which  not 
infrequently  are  found  with  posterior  spinal  sclerosis,  and  which  are 

^  Abstract  in  "  Brain,"  vol.  3,  No.  4. 
*  Op.  cit.,  p.  341. 


POSTERIOR    SPINAL    SCLEROSIS.  325 

usually  of  a  papulous  and  pustular  character.  He  mentions  the  case  of 
one  person,  who,  while  under  treatment  at  La  Salpetriere,  presented  large 
patches  of  urticaria,  the  appearance  of  which  was  coincident  with  the 
attacks  of  pain.  Other  writers  have  called  attention  to  the  existence  of 
herpes  in  connection  with  the  pain,  and  .1  myself  have  found  patches  of 
this  eruption  in  connection  with  the  early  severe  pains  especially  on  the 
inner  surface  and  back  of  the  thighs. 

The  eruptions  generally  mark  out  the  course  of  the  nerve  which  is  the 
seat  of  pain ;  Hutchinson,  however,  considers  that  this  arrangement  of 
the  eruption  is  usually  misinterpreted,  and  that,  instead  of  the  eruption 
following  the  direction  of  a  nerve-trunk  and  its  branches,  the  corymbi- 
form  distribution  of  the  skin-disease  in  reality  corresponds  with  the  course 
of  the  small  vessels. 

Occasional  but  exceedingly  interesting  features  of  the  disease  are  the 
joint  troubles  and  certain  trophic  alterations  in  bone-tissue  leading  to 
decided  brittleness  and  liability  to  fracture.  Charcot  was  first  to  call  atten- 
tion to  these  symptoms,  and  Buzzard,  Weir  Mitchell  and  others  have  written 
extensively  about  them  since.  Arthropathic  changes  may  begin  at  any 
period  of  the  disease,  but  are  more  common  during  the  last  stage.  The 
joints  of  the  lower  extremities  seems  to  be  more  frequently  the  seat  of  swell- 
ing than  other  parts,  and  this  is  true  also,  as  Arnozan^  points  out,  regard- 
ing the  brittleness  of  bones,  those  of  thq  trunk  rarely  undergoing  change. 

The  knees  or  ankle  joints  may  be  the  seat  of  a  cold,  puffy,  soft  swelling 
of  gradual  growth,  and  nearly  always  attended  by  no  increase  in  temper- 
ature, pain  or  evidence  of  inflammatory  action.  After  a  time  it  is  possi- 
ble to  detect  a  much  greater  degree  of  mobility,  which  is  due  to  loss  of 
substance,  and  it  is  an  easy  matter  to  twist  the  limb  or  dislocate  the  bone. 
At  an  early  stage  of  the  affection  the  patient  may  find  it  impossible  to  stand, 
because  of  the  "  turning  "  of  the  ankles.  This  is  the  case  in  one  patient  I 
have  under  observation  ;  but  I  regard  a  double  symmetrical  arthropathy  a 
rare  condition.  It  is  possible  to  hyper-extend  a  limb,  so  that,  for  instance, 
a  distinct  fold  of  skin  may  be  perceived  upon  the  anterior  aspect  of  the 
knee  below  the  patella  when  the  leg  is  carried  forward,  the  patient's  ex- 
tremity presenting  the  appearance  of  that  of  a  child's  doll.  The  foot 
may  be  everted  to  a  great  degree,  or  the  thigh  dislocated  with  great 
facility.  The  muscles  about  the  arthropathy  are  often  atrophied  and  feeble, 
and  do  not  keep  the  limb  in  place.  The  articular  surfaces  may  be  felt, 
and  will  be  found  to  be  greatly  reduced  in  size. 

Charcot  and  Raymond,^  in  alluding  to  the  disappearance  of  the  heads 
of  the  long  bones,  relate  the  case  of  a  woman,  aged  52,  who  had  been  ill 
for  many  years.  The  autopsy  revealed  atrophy  of  the  difierent  processes 
of  the  humerus,  femur,  tibia,  and  scapula,  with  muscular  degeneration  of 
a  fibrous  character.     In  another  case  there  was  hip-joint  afiection,  and 


^  Des  Lesions  TropMques,  p.  86,  1880. 
=*  Gaz.  Medicale  de  Paris,  Feb.  19,  1876. 


326  DISEASES    OF    THE    SPINAL    CORD. 

great  brittleness  of  the  bones,  which  broke  when  subjected  to  inconsidera- 
ble force,  and  afterwards  united  quite  readily.  During  life  the  evidences 
of  such  arthropathies  are  sometimes  numerous.  They  may  be  illustrated 
by  the  following  case  of  Bourcere.^ 

The  patient  was  a  woman  Avho  entered  La  Charite  April  8,  1875  ;  she 
was  middle-aged,  and  presented  many  of  the  symptoms  of  locomotor 
ataxia.  These  began  about  ten  months  before.  The  left  leg  seemed  to 
be  more  affected  than  the  right.  Three  days  after  admission  the  left 
thigh  and  buttock  began  to  swell  rapidly,  and  in  a  few  hours  the 
swelliug,  which  was  not  oederaatous  in  the  strictest  sense  of  the  word,  but 
hard  and  not  painful  on  pressure,  reached  its  maximum.  It  extended  as 
far  down  as  the  knee,  where  it  stopped  abruptly.  There  Avas  no  fluctua- 
tion, nor  any  evidence  of  pus.  The  swollen  part  was  almost  double  the 
size  of  the  other  limb,  while  the  leg  was  shortened,  and  the  foot  was  to 
some  degree  rotated  outwards.  There  was  also  some  swelling  and  hard- 
ness unattended  by  tenderness  in  the  left  iliac  fossa.  The  swelling  disap- 
peared almost  entirely  in  a  week,  when  vaginal  examination  wa-i  made, 
and  a  hard,  smooth  tumor  was  discovered,  which  apparently  sprung  from 
the  pelvic  bones  of  the  left  side.  Pus  was  soon  afterwards  detected  in  the 
psoas  sheath  above  and  below  Poupart's  ligament.  She  became  pros- 
trated, and  died  on  the  6th  of  May.  After  death  decided  osseous  changes, 
to  be  hereafter  described,  were  observed. 

It  has  been  found  that  in  many  subjects  the  bones  undergo  a  chemical 
change  which  renders  them  liable  to  fracture.  This  fracture  is  sponta- 
neous and  may  be  caused  by  some  such  simple  movement  as  crossing  the 
legs  suddenly.  The  accident  may  be  preceded  for  some  days  by  an  in- 
crease in  the  violence  of  the  fulgurating  pains  and  perhaps  by  some  red- 
ness and  swelling  at  a  point.  It  is  not  rare  to  find  several  fractures  oc- 
curring after  each  other  but  there  seems  to  be  rapid  repair. 

Locomotor  ataxia  may  be  associated  with  progressive  muscular  atrophy, 
or  may  sometimes  terminate  in  general  paresis  of  the  insane.  West- 
phal  and  Obersteiner,  have  written  much  upon  the  relation  of  the 
two  diseases  and  their  possible  coexistence. 

Obensteiner,^  in  an  excellent  paper  upon  locomotor  ataxia  and  mental 
diseases,  considers  that  mental  symptoms  are  found  iu  the  greater  pro- 
portion of  cases  of  this  disease,  and  calls  attention  to  the  fact  that  these 
expressions  of  psychical  trouble  may  be  very  slight ;  still,  an  acute  ob- 
server will  know  that  there  is  a  departure  from  the  normal  intellectual 
condition.  The  patient's  character  is  changed  markedly.  I  have 
been  often  astonished  at  the  apathy  of  an  individual,  or,  on  the  other  hand, 
at  his  irritability  of  temper,  the  violence  of  his  anger,  and  his  petulance, 
which  are  more  than  transitory  evidences ;  and  they  are  as  important 
symptoms,  I  think,  as  neuralgic  pains,  difficulty  of  co-ordination,  etc. 
These  changes  were  all  well  displayed  in  a  patient  of  my  own ;  in 
health  a  most  amiable,  high-minded  person ;  in  disease  a  morbid,  bad- 

1  Progres  Med.,  Oct.  9,  1875. 

»  Wiener  Med.  Woch.,  No.  29,  1875. 


POSTERIOR    SPINAL    SCLEROSIS.  827 

tempered,  whining  wreck.  He  had  been  noted  for  his  gallantry  on  the 
field  during  the  war ;  but  after  his  disease  had  become  established,  his 
character  seemed  to  undergo  a  complete  transformation.  He  wrangled 
with  every  one,  became  irritable  over  petty  things,  and  made  himself 
generally  disagreeable. 

Obersteiner  and  Simon^  both  agree  that  these  patients  should  be  exam- 
ined most  carefully,  and  that  the  prognosis  depends  much  upon  the  facts 
relative  to  mental  alteration.  The  latter  says :  "  It  is  not  enough  that 
the  patient  keeps  himself  quiet,  and  answers  the  questions  relative  to  his 
age,  how  he  feels,  etc.,  and  does  not  show  marked  delusions ; "  these  are 
not  enough  to  assure  us  that  his  intellect  is  intact. 

In  regard  to  the  grave  secondary  mental  changes,  Tigges  considers 
general  paralysis  to  be  a  complication,  while  Obersteiner  is  convinced  that 
the  symptoms  of  this  latter  disease  indicate  a  progression  of  the  sclerosis 
upwards.  He  considers  the  lesions  to  be  identical,  and  that  it  is  only  the 
seat  of  the  change  which  has  anything  to  do  with  the  symptom  expressed. 
He  has  also  found,  in  general  paralytics  who  have  died,  a  sclerosis  of  the 
cord. 

M.  Rey  has  observed  nine  cases  of  insanity  associated  with  locomotor 
ataxia.  In  three  of  these  the'  spinal  sclerosis  preceded  the  cerebral 
trouble,  and  in  one  the  induration  had  extended  from  the  posterior  to  the 
lateral  columns.  He  found  that  the  diagnostic  difference  between  loco- 
motor ataxia  combined  with  cerebral  induration,  and  simply  descending 
general  paralysis  of  the  insane,  was  the  walk.  In  the  former  the  patient  could 
not  stand  with  his  eyes  shut,  and  in  the  latter  there  was  no  difficulty  of 
the  kind.  We  may  al-o  take  for  granted  that  the  walk  of  the  ataxic  is 
an  early  symptom,  and  that  of  the  general  paralytic  a  late  one.  Both  are 
examples  of  defective  coordination,  and  I  think  the  latter  is  unwisely 
called  paralytic. 

The  difficulty  of  turning  around  is  marked  in  ataxia,  but  it  is 
not  a  prominent  symptom  in  general  paralysis.  The  individual  walks 
steadily  across  the  floor  when  told  to  do  so,  but  when  he  has  to  retrace 
his  steps,  he'spreads  his  feet,  and  if  the  loss  of  co-ordinating  power  be  at  all 
great,  he  falls  if  he  has  no  support. 

A  case  lately  came  under  my  charge  where  the  sclerosis  of  the  cord 
was  ascending,  and  in  an  incredibly  short  time  the  cerebral  symptoms 
which  indicate  the  general  paralysis  of  the  insane  were  evident. 

M.  F.,  aged  29 ;  United  States.  On  admission  to  the  Epileptic  and 
Paralytic  Hospital,  March  6,  1876,  I  was  immediately  struck  by  the 
woman's  walk,  which  was  ataxic  in  the  extreme ;  and  on  questioning 
her  and  her  husband  we  ascertained  that  about  two  years  ago  she  had 
neuralgic  pains  in  the  legs  and  feet ;  her  walking  became  defective,  and 
has  continued  so.  Her  mind  was  clear  up  to  a  short  time.  Her  pupils  are 
now  unequally  dilated,  the  left  being  the  largest ;  her  lips  tremble  distinctly. 

^Archiv.  fiir  Psychiatrie,  i.  and  ii.,  1875. 


328  DISEASES    OF    THE    SPINAL    CORD. 

Her  tODgue,  when  protruded,  also  quivers;  when  told  to  keep  it  quiet,  the 
motion  is  greatly  exaggerated.  There  is  some  ptosis  of  the  left  eye.  When 
told  to  close  her  eyes,  she  is  unable  to  co-ordinate  delicate  muscular  move- 
ments. She  cannot  find  the  tip  of  her  nose  with  her  forefiliger  by  more 
than  an  inch.  When  her  eyes  are  open,  she  cannot  touch  small  points, 
such  as  the  markings  upon  my  watch-dial.  When  she  stands  with  her 
eyes  closed,  she  topples  over  almost  instantly.  When  she  walks,  her  toes 
are  thrown  out,  and  she  comes  down  upon  her  heels.  Her  feet  are  planted 
far  apart  when  she  attempts  to  stand.  When  walking  across  the  room, 
she  reels,  and  has  difficulty  in  turning  around.  When  attempting  to  an- 
swer questions,  she  talks  slowly,  each  word  being  uttered  with  some  effort, 
the  words  containing  theletter  "f"  and  "p"  Sire  explosive,  mid  the  lips 
seem  to  have  a  great  deal  of  work  to  form  them.  The  consonants  are 
sluiTcd  over  ;  for  instance,  the  word  "  man  "  is  pronounced  "  mah  ;  "  the 
"  I's  "  are  dropped,  as  are  many  other  letters,  Her  writing  is  very  scratchy 
and  irregular,  although  her  husband  says  she  formerly  wrote  an  excel- 
lent hand.  Mentally  she  is  silly,  and  laughs  immoderately  at  wrong 
times  and  without  cause.  She  has  no  idea  of  time,  but  seems  to  know 
what  she  is  saying.  She  has  had  several  delusions,  one  of  which  was  that 
she  had  been  home  the  day  before. 

May  12th,  two  months  after  admission. — Her  walk  is  much  worse;  no 
urinary  or  other  difficulty.  There  is  some  festination  ;  pupils  still  un- 
even. The  difficulty  in  speech  has  markedly  increased.  Her  tottering 
walk  is  striking.  We  at  first  thought  she  had  syphilis,  but  this  is  not 
so.  Being  unmanageable  and  restless,  she  was  transferred.  Here,  un- 
doubtedly, was  an  ascending  condition,  beginning  with  the  pains  and  gait 
of  locomotor  ataxia,  and  ending  with  several  early  symptoms  of  general 
paralysis, 

Charcot  has  described  a  peculiar  train  of  symptoms  accompanying  the 
pains  of  the  earlier  stages.  These  are  the  crises  gastriques,  which  are  ex- 
pressed by  pains  which  begin  in  the  groins,  and  run  up  the  abdomen  on 
either  side,  finally  becoming  fixed  at  the  epigastrium.  They  are  violent, 
and  occur  during  the  exacerbations  of  lancinating  pain  in  the  lower  ex- 
tremities. During  the  time  they  last,  there  is  violent  palj^itation,  vertigo, 
and  vomiting,  the  latter  symptom  occurring  without  relation  to  the  con- 
dition of  the  stomach.  If  there  be  no  food  to  be  expelled  from  that  or- 
gan, there  may  be  a  quantity  of  frothy  and  bloody  liquid  ejected.  These 
crises  last  two  or  three  days,  and  disappear  quite  suddenly.  Buzzard  has 
found  that  there  is  some  connection  between  them  and  the  arthro- 
pathies, and  of  nine  cases  with  joint  troubles,  six  presented  the  crises 
as  a  symptom.  Some  observers  have  noticed  the  appearance  of  ptosis 
during  their  existence,  which  gradually  disappears.  Stewart  ^  has  seen 
several  cases  in  which  these  symptoms  varied,  and  instead  of  there  being 
pain  which  started  from  the  groin,  there  was  deep-seated  pain  in  the  dor- 
sal and  lumbar  regions. 

Raynaud  has  called  attention  to  a  species  of  renal  neuralgia  which  is 
not  at  all  an  uncommon  complication.  One  of  his  cases,  which  was  mis- 
taken for  renal  colic,  presented  lumbar  pain,  vesical  tenesmus,  retraction 

1  Med.  Times  and  Gazette,  Oct.  7, 1867. 


POSTERIOR    SPINAL    SCLEROSIS.  329 

of  the  testicle  and  other  suggestive  symptoms  like  those  described  by 
Miiller.  There  was  temporary  cessation  after  a  few  days,  but  a  second  and 
third  attack  followed.  Charcot  and  other  French  writers  have  alluded  to 
various  additional  visceral  disorders,  as  found  with  this  as  well  as  other 
organic  spinal  diseases,  and  the  functions  of  the  kidney  are  sometimes 
greatly  disturbed.  I  do  not  think  that  sufficient  attention  has  been  paid  to 
forms  of  hysteria  which  resemble  locomotor  ataxia.  These,  I  believe,  are 
the  cases  which  are  cured.  Isnard  ^  has  extensively  considered  the  func- 
tional form  ;  and  Webb  and  Mitchell,  of  Philadelphia,  have  reported  very 
interesting  cases  of  genuine  hysteria  which  counterfeited  the  organic  dis- 
ease quite  closely. 

Diphtheria  is  sometimes  followed  by  a  nervous  condition  that  is  apt  to 
be  mistaken  for  true  locomotor  ataxia.  Seguin  calls  attention  to  the  fact 
that  the  ocular  trouble  consists  in  paralysis  of  the  ciliary  muscle  and 
consequent  dilated  pupils,  with  loss  of  accommodation  instead  of  the  or- 
ganic ocular  change  so  marked  in  true  spinal  sclerosis  posterior.  This 
condition,  too,  is  of  short  duration. 

Causes. — Dissipation  has  much  to  do  with  the  development  of  this 
terrible  disease,  while  onanism  and  venereal  excesses,  especially  play  an 
important  part ;  so  that  we  may  expect  to  find  it  among  men  about  town, 
hard  drinkers,  and  other  people  of  bad  habits.  Injury,  exposure  to  rain  and 
cold;  syphilis,  and  protracted  mental  excitement,  favor  its  origin.  These 
are  rare  cases,  and  I  have  seen  one  in  which  the  disease  suddenly  appeared 
after  injury,  running  a"  peculiarly  rapid  course.  At  the  Hospital  for 
Epileptics  and  Paralytics  there  is  such  a  case  in  the  person  of  a  German 
workman  who  broke  his  femur,  the  fracture  being'simple.  He  was  carried 
to  the  hospital  and  his  injuries  were  treated  in  the  usual  way.  After  four 
or  five  weeks  he  began  to  have  the  fulgurating  pains,  and  within  four 
months  there  have  appeared  all  of  the  pronounced  symptoms  of  a  grave 
case.  He  can  hardly  stand,  and  cannot  walk  without  clinging  to  the 
sides  of  his  bed.  He  has  complete  loss  of  the  "  tendon  reflex,"  commenc- 
ing optic  atrophy,  immobile  pupils,  difficult  deglutition,  etc.  Petit,^  in 
referring  to  the  traumatic  origin  of  the  disease,  does  not  allude  to  the 
rapid  form,  but  contents  himself  chiefly  with  considering  the  influence  of 
injury  upon  the  established  affection.  He  considers  that  falls  upon  the  back, 
nates,  or  direct  jarring  of  the  cord  transmitted  by  a  fall  upon  the  feet, 
are  favorable  to  the  development  of  the  disease.  Some  sudden  exposure, 
such  as  a  fall  into  the  water,  or  a  night  in  the  rain,  may  be  the  exciting 
cause,  and  several  of  my  cases  had  such  a  beginning.  Rosenthal  ^  reported 
sixty-five  cases,  forty-six  of  which  were  males  and  nineteen  females  ;  and 
of  this  number  thirty-one  were  traced  to  libidinous  excesses,  seven  to  ex- 
haustion, and  twenty -seven  to  cold  and  exposure.     The  youngest  of  these 

1  L'Union  Medicale,  131,  134,  135,  137,  141,  142,  1862.     Abst.  in  Lancet,  Sept. 
30,  1875. 

2  Kevne  Mensuelle,  No.  3,  1879. 

»  Wien,  Med.  Woch.,  1869,  No.  251. 


330  DISEASES    OF    THE    SPINAL    CORD. 

patients  was  niueteen,  and  the  oldest  sixty-eight.  The  ages  at  which  the 
disease  appears  is  rarely  before  the  thirtieth,  aud  never  after  the  sixtieth 
year.  Heredity  seems  to  have  much  to  do  with  its  development,  for 
instance,  Friedreich'  reports  six  eases  which  occurred  in  two  families; 
and  two  of  these  patients  were  males,  and  four  were  females.  The  heads 
of  the  families  were  drunkards.  Before  the  Clinical  Society  of  London, 
Gowers^  presented  the  histories  of  five  cases  of  locomotor  ataxia  in  the 
same  family.  The  mother  had  had  chorea  in  early  life,  but  the  father 
himself  was  healthy,  though  some  of  his  brothers  had  been  insane.  There 
were  nine  children  in  the  family.  "  1.  A  son,  aged  39,  with  well-marked 
ataxy,  which  commenced  at  nineteen.  He  is  just  able  to  walk  with 
crutches.  There  is  inco-ordination  of  the  arms  and  affection  of  articula- 
tion. Sensation  to  touch  is  normal,  that  to  pain  is  in  the  legs  increased. 
The  knee-jerk  is  lost.  2.  A  girl  who  died  of  fever  at  ten  years  old. 
3.  A  son,  aged  thirty-five,  healthy.  4.  A  sou,  aged  thirty-three,  healthy. 
5.  A  girl,  aged  twenty-nine,  in  whom  the  afiection  commenced  at  eigh- 
teen. She  can  now  scarcely  stand ;  there  is  weakness  in  the  legs  as  well 
as  ataxy,  and  also  inco-ordination  of  the  arms.  Speech  is  affected,  sensa- 
tion is  normal,  the  leg-jerk  is  lost.  6.  A  son,  aged  twenty-six,  perfectly 
well.  7.  A  son,  aged  twenty-three,  considerably  afiected, — the  disease 
showed   itself  at   nineteen.  *  *  *  *      8.  A  son, 

aged  twenty-two,  reported  to  be  well,  but  found  on  examination  to  be 
distinctly  affected.  *  *  9.  A  son,  aged  niueteen,  affected  in  rather 
a  greater  degree  than  the  last."  These  two  cases  showed  all  the  early 
symptoms — inability  to  stand  with  eyes  closed,  absent  tendon  reflex,  and 
confluent  articulation.  Friedreich  and  Dr.  A.  Carpenter  have  also  pre- 
sented cases — the  latter,  two  cases  in  the  same  family  ;  but  it  is  question- 
able whether  Friedreich's  cases  were  true  locomotor  ataxia.  Syphilis,  as 
I  have  said,  is  sometimes  at  the  root  of  locomotor  ataxia,  and  perhaps 
is  the  most  fortunate  cause  to  discover,  as  it  greatly  alters  the  prog- 
nosis of  the  disease.  It  must  be  understood  that  the  lesion  is  purely 
syphilitic  ;  and  the  symptoms  result  simply  from  the  presence  of  a  gum- 
ray  infiltration  or  tumor  in  the  posterior  columns,  and  not  from  any  in- 
duced sclerosis.  Erb  is  disjjosed  to  lay  great  stress  upon  the  frequency  of 
the  association  of  syphilis  and  the  disease  under  consideration. 

Morbid  Anatomy  and  Pathology. — The  cord  of  the  ataxic, 
when  cut  into,  will  present  an  appearance  which  is  distinctive.  The  pos- 
terior columns  will  be  found  to  be  more  gray  and  dark  than  they  should 
be,  aud  there  may  be  hard  deposits  on  either  side  of  the  posterior  fissure. 
Beneath  the  microscope  the  peculiar  thickening  of  the  connective  tissue 
will  be  found  to  have  taken  place  at  the  expense  of  the  nervous  elements. 
Lockhart  Clarke  thus  tersely  describes  the  changes  that  take  place : — 
"  The  moi'bid  anatomy  of  locomotor  ataxia  consists  chiefly  of  a  certain 
gray  degeneration  and  disintegration  of  the  posterior  columns  of  the  spinal 
cord,  of  the  posterior  roots  of  the  spinal  nerves,  of  the  posterior  gray  sub- 

1  Vircbow's  Archiv.,  xxvi.,  pp  391,  433.    '  London  Lancet,  Oct.  16,  1880,  p.  G18. 


POSTERIOR    SPINAL    SCLEROSIS.  331 

stance  or  cornua,  and  sometimas  of  the  cerebral  nerves.  A  variable 
number,  and  frequently  in  the  latter  stages  of  the  disease  nearly  all  the 
fibres  of  the  posterior  column  and  posterior  roots,  fall  into  a  state  of 
granular  degeneration  and  ultimately  disappear.  Usually  the  posterior 
columns  retain  their  normal  size  and  shape  in  consequence  of  hypertrophy 
of  connective  tissue  which  replaces  the  lost  fibres. 

"  In  this  tissue,  at  wide  but  variable  intervals,  lie  imbedded  the  remain- 
ing nerve-fibres,  with  the  debris  of  their  neighbors  in  difierent  stages  of 
disintegration.  In  some  places  they  are  severed  into  small  portions,  or 
into  rolls  or  lobular  masses  formed  out  of  the  medullary  sheaths  of  white 
substance,  which  has  been  stripped  from  their  axis  cylinders.  In  other 
places  they  have  fallen  into  smaller  fragments  and  granules,  which  are 
either  aggregated  in  the  line  of  the  original  fibres  or  scattered  at  irregular 
distances.  Corpora  amylacea  are  usually  abundant,  and  oil-globules  of 
difierent  sizes  are  frequently  interspersed  among  them  and  collected  into 
groups  of  variable  shape  and  size  around  the  blood  vessels  of  the  part.  I 
am  inclined  to  believe  from  my  own  investigations  that  in  the  course  of 
the  disease  the  posterior  cornua  of  gray  substance  are  more  or  less  af- 
fected, and  it  appears  to  me  to  be  a  question  whether  they  are  not  the 
first  parts,  or  at  least  among  the  first  parts  that  are  morbidly  changed.  I 
have  also  shown  that  in  some  cases  the  deeper  central  parts  of  the  gray 
substance  are  more  or  less  injured  by  areas  of  disintegration.  These  lat- 
ter lesions,  however,  are  not  essential  to  the  production  of  locomotor 
ataxia,  the  peculiar  symptoms  of  which  depend  solely  on  lesions  of  the 
posterior  columns  of  the  posterior  nerve-roots,  and  j)robably  of  the  poste- 
rior cornua.  The  cases  in  which  they  occur  may  be  considered  as  mixed 
cases,  partaking  of  the  nature  of  locomotor  ataxia  and  common  spinal 
paralysis."  Charcot  and  Pierret  do  not  consider  sclerosis  of  the  fillets  or 
columns  of  Goll  to  be  the  essential  lesion  of  the  disease  under  considera- 
tion. They  rather  hold  that  the  degenerative  process  begins  in  the  lateral 
parts  of  the  posterior  columns.  It  has  been  shown  that  the  nerve-roots 
themselves  need  not  necessarily  be  afiected,  although  the  cornua  may  be 
degenerated  most  completely. 

^Numerous  interesting  experiments  have  been  made  by  Schifi",^  Ludwig,^ 
and  others,  some  quite  recently  by  Ott,^  and  G.  B.  W.  Field,*  in  this  country, 
that  are  likely  to  change  our  views  materially,  not  only  with  regard  to  the 
pathology  of  this  disease,  but  of  many  others.  These  authors,  with  the  excep- 
tion of  the  first-mentioned,  hold  that  the  lateral  columns  of  the  cord  are 
the  regions  in  which  the  conductors  for  voluntary  impulses,  inhibitory 
nerves,  sudorific  nerves,  vasomotor  impulses  and  sensations  of  pain  are  situ- 
ated, while  the  posterior  columns  "  conduct  tactile  impressions  and  co  ordi- 
nation impulses."   The  gray  matter,  according  to  the  carefully-made  expe- 

^  Lehrbuch  der  Physiologie  des  nervensystems,  1859. 

2  Ludwig's  Arbeiten. 

3  American  Med.  Journal,  Oct.,  1879. 

*    Journal  of  Mental  and  Nervous  Disease,  April,  1881. 


332 


DISEASES    OF    THE    SPINAL    CORD, 


riments  of  Field,  lias  no  office  in  the  conduction  of  any  of  these  impressions. 
It  would  appear,  then,  that  so  far  as  definite  co-ordination  and  impairment 
in  the  reception  of  tactile  impressions  goes  that  the  posterior  columns  are 
concerned  ;  but  that  the  disease  must  involve  the  lateral  bauds  of  this 
region,  and  involve  either  commissurally  or  directly  the  lateral  columns 
themselves,  to  give  rise  to  the  phenomena  of  pain  that  belong  to  locomotor 
ataxia.  This  agrees  perfectly  with  the  statement  of  Erb,'  that  "  the  typi- 
cal form  of  tabes  does  not  depend  exclusively  upon  disease  of  the  posterior 
columns  of  the  spinal  cord,  but  that  other  parts  in  the  vicinity  of  the  pos- 
terior columns  must  also  be  involved  in  the  disease."  If  the  columns  of 
Goll  are  involved  it  will  be  later.  The  sclerosed  parts  of  the  cord  in  this 
disease  are  more  commonly  the  lumbar  and  lower  dorsal,  although  the 
cervical  portion  may  be  invaded  as  well.  The  case  mentioned  by  Noth- 
nagel  presented  sclerosis  of  the  entire  posterior  columns. 

The  bones  undergo  remarkable  changes  before  referred  to,  and 
after  death  the  result  of  such  arthropathic  alterations  may  be  seen  iu 
atrophy,  exfoliation,  shortening,  and  destruction  of  their  articular  surfaces. 
The  appearance  of  old  fracture  is  admirably  shown  in  Fig.  50,  which 
is  taken  from  Charcot.     A  peculiar  osseous  change  has  been    noted  by 


Fig.  50. 


Appearance  of  Trophic  Bone  Changes  in  Locomotor  Ataxia.    (Charcot.) 

Luys  and  others,  and  this  consists  in  wasting  of  the  alveolar  processes 
so  that  the  teeth  lose  their  support  and  drop  out. 

The  interest  connected  with  the  various  phases  of  altered  nutrition  of 
bony  tissue  as  a  consequence  of  spinal  disease,  depend,  to  a  great  extent, 
upon  the  discovery  of  ^  Rauber  and  Talamon,^  the  first  of  whom  discovered 


1  Article  in  Ziemssen's  Cyclop.,  vol.  xiii.,  p.  602. 
»  Centralblatt  No.  20,  p.  305,  1874. 
^  Pwevue  Mensuelle,  1878,  vol.  ii. 


POSTERIOR    SPINAL    SCLEROSIS.  333 

corpuscular  termination  of  nerves  in  synovial  membranes  and  ligaments. 
What  the  exact  nature  of  this  connection  is  remains  to  be  studied.  Tala- 
mon  reports  a  case  of  arthropathy  in  which  there  was  no  disease  of  the 
large  cells  in  the  anterior  columns,  and  the  researches  of  Charcot  are 
equally  unsatisfactory  in  pointing  to  the  trouble  as  a  result  of  the  same 
processes  which  enter  to  so  great  a  degree  in  such  other  diseases  as  infan- 
tile paralysis  and  the  like.  The  conclusions  of  ^Buzzard  seem  to 
throw  light  upon  the  subject,  however.  This  writer,  who,  as  has  been 
stated,  found  that  the  crises  gastrique  were  most  frequent  in  patients 
who  presented  arthropathies,  and  that  decided  lesions  of  the  radicular  fibres 
of  the  pneumogastric  probably  existed,  concluded  that  in  the  neighbor- 
hood there  was  another  bulb  or  centre,  which  was  likewise  affected, 
and  as  a  result  the  osseous  changes  occurred.  ^  Arnozan  is  not  disposed  to 
accept  Buzzard's  view  in  their  entirety,  and  is  rather  inclined  to  look  for 
the  lesion  in  the  sensory  region  of  the  spine,  and  he  is  led  to  this  opinion 
by  the  association  of  arthropathies,  with  an  increase  in  the  symptomatic 
pains  in  the  extremities. 

If  Buzzard's  autopsical  results  bear  out  the  connection  between  dis- 
ease of  the  nucleus  of  the  pneumogastric,  and  the  existence  of  crises  and  of 
arthropathies,  it  may  raise  the  question  of  trophic  changes  as  a  result 
of  general  nutritive  disorder.  This  seems  plausible  when  we  realize  the 
fact  that  chemical  alteration  in  the  bones  of  ataxics  has  been  found  by 
^Kegnard,  who  discovered  that  the  phosphates  had  diminished  in  propor- 
tion, as  the  fatty  matter  had  increased. 

The  fractures  of  the  bones  of  ataxics  are  characterized  by  the  rapidity 
with  which  union  takes  place,  the  exudation  of  callus  being  remarkably 
rapid,  as  was  shown  in  Richet's  example,  who  died  a  few  weeks  after  a 
spontaneous  fracture. 

The  cranial  nerves  are  frequently  affected,  their  course  being 
interrupted  by  patches  of  degeneration.  The  induration  attacks  the 
periphery  first,  and  extends  to  the  centre,  and  the  changes  begin  at  the 
point  of  origin  of  the  nerve  and  progress  towards  its  distal  end.  The 
optic  disk  is  nearly  always  found  to  be  atrophied  and  blanched,  but  there 
seems  to  be  no  change  in  the  size  of  the  retinal  vessels.  There  are  often 
evidences  of  injection  of  the  investing  membranes  of  the  cord  or  actual 
meningitis,  and  six  cases  which  were  reported  by  Friedreich  presented 
opacity,  and  thickenin'g  of  the  pia  mater,  which  was  adherent  to  the  cord ; 
I  doubt  if  there  are  many  examples  in  whicb  some  form  of  menin- 
gitis has  not  existed  at  some  time  or  other.  Charcot  ^  alludes  to  the  gray 
degeneration  of  the  optic  nerves  as  an  evidence  of  the  amaurosis  that  is  so 
prominent  a  symptom,  and  he  calls  the  pathological  condition  "  nevrite 
parenchymateuse."     Stilling  has  recently  discovered  a  spinal  root  of  the 

1  London  Lancet,  Feb.  7,  1880. 

2  Op.  cit  p  94. 

'  Gazette  Medicale  de  Paris,  Feb.  7,  1880. 

*  Lecons  sur  le  Syst.  nerveux,  2eme  serie,  1  fascic. 


334  DISEASES    OF    THE    SPINAL    CORD. 

optic  nerve  which  passes  from  the  external  corpus  geniculatura,  follows  a 
deep  course  in  the  crus  and  is  lost  sight  of  in  the  medulhi,  and  this 
suggests  an  explanation  of  the  causation  of  the  optic  nerve  atrophy  even 
when  there  is  no  cerebral  disease. 

Much  of  the  interest  belonging  to  this  disease  is  connected  with  the 
phenomena  of  inco-ordination,  and  a  lesion  that  may  affect  the  integrity 
of  the  organs  intended  for  the  transmission  and  reception  of  visual,  au- 
ditory, or  tactile  impressions  will  result  in  a  loss  of  equilibriating  power. 
According  to  Ferrier,  the  apparatus  provided  for  the  maintenance  of 
equilibrium  consists  of  :  1,  a  system  of  afferent  nerves  ;  2,  a  co-ordinating 
centre ;  3,  efferent  tracks  in  connection  with  the  muscular  apparatus 
concerned  in  the  action.  Of  course  lesions  of  one  or  all  of  these  parts 
must  result  in  a  loss  of  balancing  power.  Perhaps  the  most  important 
factor  in  the  preservation  of  equilibrium  is  tactile  sensibility.  The  frog, 
deprived  of  his  skin,  loses  the  power  of  co-ordination,  for  the  co-ordinating 
centre  is  deprived  of  the  exciting  organ  from  which  impressions  are  trans- 
mitted. So,  too,  may  this  loss  follow  sudden  destruction  of  one  of  the 
peripheral  organs  of  special  sense.  As  has  been  shown  by  Volkmann, 
the  exposed  ends  of  the  nerves  are  not  sufficient  to  transmit  the  sensory 
impression,  but  it  is  necessary  that  their  cutaneous  terminations  shall  ex- 
ist. When  the  tactile  sensation  in  the  ataxic  is  blunted,  or  the  impres- 
sions are  interrupted  in  their  upward  course,  as  has  been  held  by  Schiff, 
we  have  a  loss  of  co-ordinating  power  which  is  a  striking  feature  of  loco- 
motor ataxia.  It  is  not  necessary  for  consciousness  to  enter  into  equilibria- 
tion  and  co-ordination,  for,  as  we  well  know,  many  acts  are  purely  spinal 
in  character,  and  become  automatic  to  some  degree ;  and  walking  is  no- 
tably one  of  these  acquired  automatic  movements.  Acephalous  monsters 
have  performed  a  number  of  acts  which  were  strongly  reflex  ;  and  ani- 
mals from  whom  the  brains  have  been  removed  are  able  to  co-ordinate  to 
a  certain  degree  after  the  first  shock  of  the  operation  has  passed  by.  In 
the  disease  under  consideration  consciousness  enters  to  a  decided  extent 
when  the  harmony  of  the  co-ordinating  centres  is  lost.  This  conscious- 
ness is  exhibited  in  vertigo,  and  is  exerted  in  the  ineffectual  effort  to  regu- 
late the  actions  of  the  limbs,  the  brain  endeavoring  to  supply  the  lost 
automatic  sense.  Broad  bent  ^  considers  that  there  are  two  co-ordinating 
centres ;  one  in  the  cerebellum,  and  the  other,  as  I  have  stated,  in  the  cord. 
Vision  holds  the  same  relation  to  the  cex'ebellar  co-ordinating  power  that 
tactile  sensibility  does  to  the  cord  centre.  For  instance,  a  tight-rope  walker 
would  fall  were  it  not  for  the  aid  of  vision,  although  the  tactile  sensibility 
becomes  so  perfectly  educated  that  it  may  take  the  place  of  the  eyes  in  ena- 
bling the  performer  to  regulate  his  actions  when  he  is  blindfolded.  The 
tactile  sense  is  of  a  lower  grade,  and  when  this  fails  the  individual,  as  is 
the  case  with  the  ataxic,  requires  more  than  ever  the  aid  of  vision.  In 
the  normal  condition  he  may  close  his  eyes,  and  still  be  able  to  walk  in 
the  dark  with  some  ease  ;  but  if  the  tactile  sensibility  be  affected,  as  it  is 

^  Brit.  Med.  Journal,  April,  1875. 


POSTERIOR    SPI>'AL    SCLEROSIS. 


335 


in  the  disease  under  consideration,  and  if  the  aid  of  his  vision  be  denied 
him,  he  is  utterly  helpless  to  regulate  his  muscular  movements.  In  the 
daylight  he  still  has  the  power  of  helping  himself,  for  vision  comes  to  his 
assistance.  In  health  this  delicacy  of  co-ordination  may  iDe  trained  to  a 
marvellous  degree.  I  have  repeatedly  witnessed  the  feats  performed  by 
a  French  juggler,  which  illustrated  the 
nicety  of  appreciation  of  weight  it  is  pos- 
sible to  arrive  at  by  practice.  He  would 
throw  into  the  air  a  heavy  cannon  ball 
and  a  pellet  of  paper,  alternately  catching 
them  and  tossing  them  up  again,  and  the 
muscular  movements  were  regular  and 
harmonious,  and  indicated  no  effort  what- 
ever. In  locomotor  ataxia  this  power  of 
appreciation  is  sometimes  lost  to  a  marked 
degree.  To  some  ataxic  individuals  a 
four-pound  weight  seems  no  heavier  than 
one  of  two  pounds  would  if  the  patient 
were  in  normal  condition,  and  if  his  mus- 
cular movements  were  properly  co-ordi- 
nated. 

One  of  the  most  interesting  features  of 
the  disease  is  the  question  of  absent  tendon 
reflex.  I  have  already  expressed  my 
doubts  in  regard  to  the  universality  of  this 
symptom,  but  when  the  tendon-reflex  is 
absent  it  indicates  beyond  all  doubt  a  lesion 
of  the  cord  above  the  third  or  fourth 
lumbar  nerves  as  Prevost  has  demon- 
strated. Some  authors  believe  the  "  tendon- 
reflex  "  to  be  purely  a  local  phenomenon 
and  among  them,  my  friend.  Dr.  Augustus 
Waller,^  of  London,  has  advanced  the  idea 
that  there  is  no  such  thing  as  a  true  spinal 
tendon  reflex,  basing  his  conclusion  upon 
the  fact  that  the  appearance  of  the  clonic 
spasm  occurs  too  soon  after  the  application 
of  the  stimulus.  This  he  demonstrated 
by  the  myograph.  He,  therefore,  consid- 
ers that  the  phenomenon  is  due  to  a  changed  condition  of  the  muscular 
contractility  dependent  upon  some  alteration  in  local  innervation.  Dr. 
Buzzard,  on  the  contrary,  in  a  series  of  elaborate  papers,  takes  the 
opposite  view,  and  says  that  it  is  a  spinal  reflex  in  every  way,  and  that  the 
shortness  of  interval  between  the  application  of  the  stimulus  and  the 
appearance  of  the  contraction  which  is  apparently  inconsistent  with  phy- 


The  Course  of  Posterior  >'erve-Roots. 
(Clarke.) 


1" Brain"  Parts.  1880. 


336  DISEASES    OF    THE    SPINAL    CORD. 

siological  mensuration  of  time,  is  quite  possible  when  the  sensibility  of 
the  nervous  arc  is  exalted  or  in  a  favorable  condition.  He,  therefore,  can 
not  take  the  physiological  standard  of  time  as  the  pathological.  Prevost 
has  in  animals  made  pressure  upon  the  aorta,  and  as  a  consequence  the  ten- 
don reflex  was  abolished  and  did  not  return  until  the  pressure  was  remitted. 

The  arrangement  of  the  sensory  fibers  of  the  posterior  columns  is 
such  that  a  lesion  of  either  the  white  or  the  gray  matter  must  in- 
terfere with  the  conductivity  of  sensory  impressions.  Lockhart  Clarke's 
histological  researches  have  thrown  much  light  upon  the  subject.  Ac- 
cording to  him,  the  posterior  root-fibers  enter  the  cord  in  three  direc- 
tions, some  passing  in  at  right  angles  to  the  longitudinal  fibers  of  the 
posterior  column,  then  passing  across  the  same  as  well  as  the  gray  sub- 
stance, then  bending  and  continuing  longitudinally  downward,  next 
passing  into  the  gray  matter  of  the  anterior  cornua,  and  finally  termi- 
nating in  fasciculi  which  intermingle  with  the  fibers  of  the  anterior 
roots,  or  extend  into  the  anterior  columns.  Other  fibers  (those  of  the 
second  class)  run  across  the  posterior  columns,  or  cross  to  the  other  side 
of  the  cord  in  the  posterior  commissure,  or  extend  deeply  into  the  poste- 
rior columns  of  the  same  side ;  and  others  pass  forward  into  the  gray 
matter  of  the  anterior  cornua.  The  third  kind  of  posterior  spinal  roots 
enter  obliquely ;  and  certain  fibers  pass  upwards  and  downwards,  and 
become  associated  with  fibers  above  and  below  them.  The  remaining 
fibers  take  an  oblique  course,  and  run  upwards  and  downwards,  the 
greater  number  taking  the  former  direction  and  passing  finally  into  the 
gray  matter.  It  will  be  seen  that  a  lesion  affecting  the  posterior  columns 
of  the  cord  will  destroy  the  communication  of  the  nerve-roots  with  the 
gray  matter,  or  press  upon  the  sensory  fibres,  causing  peripheral  pain. 
The  communication  with  the  parts  above  is  destroyed,  and  should  the 
sclerosis  involve  the  anterior  gray  matter  there  may  be  paralysis  and 
atrophy.  A  favorite  theory,  accepted  by  many  writers,  is  that  which 
considers  that  there  are  numerous  centres  of  co-ordination  in  the  cord, 
which  are  connected  by  longitudinal  fibres,  and  that  when  these  fibers 
are  destroyed  there  results  a  species  of  inco-ordiuation.  Dienlafoy^  divi- 
ded the  posterior  fasciculi  at  diflferent  heights,  but  without  producing  any 
marked  defects  in  co-ordination,  a  result  which  seems  to  disprove  this  idea. 

Onimus^  explains  the  rigidity  and  awkwardness  of  the  movements  in 
locomotor  ataxia  by  the  theory  that  the  stifiness  of  the  muscles  is  perceived 
by  the  individual,  and  to  overcome  this  he  expends  a  greater  amount 
of  force  than  is  needed  for  the  particular  act.  The  initial  stiffness  comes 
from  the  irritation  of  the  anterior  and  lateral  columns  by  the  7iyechanical 
presence  of  the  deposit  in  the  posterior  columns. 

Diagnosis. — It  is  important  to  distinguish  locomotor  ataxia  from 
chronic  myelitis,  progressive  mitscular  atrophy,  chorea,  cerebellar  disease, 
aud  hysterical  paraplegia.  The  former  occasionally  resembles  ataxia, 
but  with  ordinary  care  no  mistakes  need  be  made.     The  paralysis  of 

^  Th^se  de  Concours,  1875.  *  Gazette  des  Hopitaux,  July,  1878. 


POSTERIOR    SPINAL    SCLEROSIS.  337 

transverse  myelitis  is  very  marked,  and  the  implication  of  the  bladder 
and  sphincter  ani  causes  the  patient  to  void  his  urine  and  feces  involun- 
tarily, which  is  not  the  case  in  locomotor  ataxia.  The  strong  ammoniacal 
odor  of  decomposed  urine  is  itself  almost  a  sufficient  diagnostic  mark. 
There  is  an  absence  of  power  in  the  legs,  and  none  of  the  pain  which 
characterizes  sclerosis  of  the  posterior  columns.  Ocular  trouble  and  in- 
co-ordination  are  likewise  absent.  If  the  gait  of  the  two  diseases  be  com- 
pared, it  will  be  found  that  in  the  former  the  legs  will  be  thrown  out  with 
some  degree  of  violence,  and  the  heel  will  come  down  forcibly.  In  the 
paraplegia  of  myelitis,  the  legs  will  be  drawn  after  each  other,  the  inner 
edge  of  the  sole  scraping  the  ground  ;  and  there  is  often  a  shrug  of  the 
body  required  to  bring  the  feet  forwards.  The  walk  of  the  hemiplegic 
is  also  different,  as  one  leg  is  swung  forwards,  the  toe  describing  an  arc, 
or  else  the  foot  is  advanced  in  a  straight  line,  the  sole  hardly  clearing 
the  floor.  Myelitis  in  its  early  stages  sometimes  resembles  posterior  spi- 
nal sclerosis.  The  pain  in  the  back,  however,  is  characteristic,  and  the 
ulterior  paralysis  and  bladder  trouble  are  sufficient  in  themselves  to  clear 
up  the  diagnosis,  though  the  constricting  band  about  the  waist  may  ex- 
cite our  suspicion.  Cerebellar  disease  has  been  spoken  of  by  Radcliffe^ 
as  a  condition  that  may  sometimes  be  mistaken  for  locomotor  ataxia. 
The  movements  are  somewhat  different,  however,  for  the  patient  rolls  and 
sways  to  a  greater  degree,  and  does  not  present  the  peculiar  jerking  gait 
of  the  ataxic.  Local  pain  is  another  symptom  peculiar  to  the  cerebellar 
condition,  and  vomiting  is  also  suggestive  of  this  affection,  but  not  of 
locomotor  ataxia.  Progressive  muscular  atrophy  in  its  earlier  stages 
may  be  mistaken  for  locomotor  ataxia.  The  wasting  of  the  muscles  in 
anomalous  cases  may  be  imperceptible,  and  the  unsteadiness  of  the  indi. 
vidual  may  alone  attract  attention.  This,  with  the  pain,  may  raise  a 
doubt  as  to  the  true  nature  of  the  malady.  Hysterical  ataxia,  such 
as  has  been  described  by  Webb,  as  a  rule,  is  not  symptomaized  by  pain, 
and  the  ataxia  is  not  genuine.  Syphilis,  in  some  of  i^s  forms,  also  occa- 
sionally produces  symptoms  which  are  very  much  like  those  of  this  dis- 
ease ;  and  there  may  be  paralysis  of  cranial  nerves,  with  pain  over  the 
tibia,  which  may  be  misleading,  when  in  reality  no  spinal  disease  exists. 

Chauvet,'  in  his  excellent  article  upon  the  influence  of  syjDhilis  in  the 
genesis  of  nervous  disease,  dwells  upon  the  connection  of  syphilis  with 
locomotor  ataxia,  and  quotes  many  authors  to  show  that  the  co-existence 
of  these  two  diseases  is  a  pure  coincidence. 

In  a  table  showing  their  relation,  eighty-five  cases  of  ataxia  are  presented  ^ 

Reporter.  Syphiliti'  Patients.  Ataxics. 

FoLirnier 24 among 30 

Vulpian 15 .      "        20 

Feretjl 6  .....    .       "        ......  11 

Siredey 6-8 "        10 

Caizergues 8 *'        14 

iQp.  cit.,  vol.  ii.  p.  683. 

''■  Influence  de  la  Syphilis  sur  les^  Maladies  du  Systems  Xerveux  Central,  p.  53;_ 
Paris,  1880. 

22 


338 


DISEASES    OF    THE    SPINAL    COED, 


His  conclusion  is  that  syphilis  has  nothing  to  do  with  the  actual  de- 
velopment of  primitive  sclerosis  of  the  posterior  columns,  but  the  presence 
of  syphilitic  deposit  in  this  region  may  undoubtedly  give  rise  to  symptoms 
closely  resembling  those  of  the  uncomplicated  disease. 

Buzzard  holds,  however,  that  in  nearly  all  cases  of  locomotor  ataxia, 
either  that  some  remote  or  recent  history  of  syphilis  is  disclosed. 

Prognosis. — Among  the  number  of  cases  reported  by  various  ob- 
servers, I  have  not  found  many  well-authenticated  cures.  An  interesting 
fact,  however,  has  been  observed  by  Gowers,  who  states  that  in  the  cases  of 
this  disease  he  has  seen — and  they  wei-e  a  great  many — that  in  families, 
those  persons  who  reached  the  age  of  twenty-five  without  showing  symptoms 
are  exempt,  although  other  members  of  the  same  family  may  have  been 
affected.  So  important  does  he  consider  this  fact  that  in  one  family  in 
which  there  were  three  members  affected,  he  recommended  the  application 
of  a  fourth  member  who  presented  himself  as  an  applicant  for  a  life-insu- 
rance policy.  In  regard  to  this  question  of  age,  it  must  be  admitted  that 
it  is  often  a  most  difficult  matter  to  say  when  the  disease  began,  for 
the  early  pains  are  mistaken  for  other  troubles.  The  following 
table  gives,  besides  other  facts,  the  ages  and  sexes  of  eight  individuals 
affected.  And  it  will  be  noticed  that  the  disease  began  in  these  cases  as 
follows:  37,  41,  40,  32,  45,  55,  36  and  42.  It  is  barely  possible  that  in 
some  of  these  cases  the  first  stage  was  not  characterized  by  pain  intense 
enough  to  engage  the  patient's  attention. 

AN  ANALYSIS  OF  EIGHT  CASES  OF  LOCOMOTOR  ATAXIA  AT  THE  HOSPITAL  FOR 
EPILEPTICS  AND  PARALYTICS,   NEW   YORK  CITY. 


•2  1  2  !  o!  Duration. 


Probable 
Cause. 


A  taxic 
Members. 


Locationandl 
Character} 
of  Fain. 


Tendon- 

Beflex. 


Disturbance 
of  Surface 
Sensation. 


Ocular 
Symptoms. 


Cerebral 
Symptoms. 


1M45 

2iM53 

3  M  54 

4  F  J52 
.'m.J59 

M57 


8  years.    Syphili.=and^     Legs.     Back  and 
thiglis. 


exposui'e. 
Unknown. 


Excessive 
venery. 

Unknown. 


Intemper- 
ance. 


Legs  and  I  Arms,  legs, 
arms.         viscera. 


Legs  and 
arms. 

Legs  and 

arms. 

Legs. 


Legs  and 

arms. 

Legs  and 
arms. 


Legs  and 
arms. 


Legs. 
Back,  legs. 

;c  < 

Legs. 


Absent. 


Increased 

to  marked 

degree. 

Well 
Marked. 

Increased. 


Increased. 


Angesthesia 


None. 
None. 


Atrophy  of 
optic  nerve. 

Atrophy  of 
optic  nerve. 

Atrophy  of 
optic  nerve 


Normal. 


Impaired 
vision. 


Dimness  of 
vision  due 
to  atrophy 
of  disks. " 


Vertigo. 
None. 


Vertigo  and 
epilepsy. 

Occasional 
epileptic 
attacks. 

None. 


Frontal  head 
ache  (a  cc 
incidence! 

None. 


POSTERIOR    SPINAL    SCLEROSIS.  339 

A  peculiarity  of  the  disease  is  the  long  intervals  of  improvement  which 
occasionally  occur ;  and  the  disease  may  be  stationary  for  years,  but  this 
is  very  rarely  the  case.  I  know  of  two  cases  which  were  so  much  im- 
proved, and  remained  so  well  for  three  or  four  years,  that  I  flattered 
myself  that  I  had  cured  them,  but  I  have  since  seen  a  change  for  the 
worse  in  both  patients.  Balfour^  presented  a  case  of  locomotor  ataxia 
which  he  claims  to  have  cured.  Pollard^  reports  a  case  which  began 
rather  suddenly,  and  disappeared  quite  rapidly  under  treatment.  Vidal,^ 
Duqueit,*  and  Herschell,^  all  report  cures.  Vidal's  patient,  a  man  of  45, 
recovered  in  three  months,  and  Duqueit's  and  Herschell's  cases  I  consider 
doubtful  as  regards  diagnosis. 

Treatment. — From  the  very  nature  of  the  disease,  the  treatment 
must  be  empirical.  Nitrate  of  silver  has  been  recommended  by  Wun- 
derlich,  Charcot,  Vulpian,  and  others,  and  has  enjoyed  great  popularity 
as  a  remedy.  Balfour,  already  alluded  to,  states  that  he  cured  q,  patient 
in  three  months  by  half-grain  doses  of  this  salt  repeated  three  times  a 
day,  and  by  the  use  of  a  foot-bath  in  which  a  quantity  of  common  salt 
had  been  thrown.  The  feet  were  also  submitted  to  the  influence  of  a 
faradic  current  passed  through  the  water  by  proper  appliances.  The 
salts  of  silver  may  be  used  with  considerable  impunity  without  discoloring 
the  skin,  and  an  unnecessary  degree  of  timidity  has  been  shown  in  their 
employment.  It  is  well,  however,  to  begin  with  a  quarter-grain  dose, 
and  it  may  be  increased  to  a  half,  or  even  a  grain,  thrice  daily."  One 
case  of  my  own  was  greatly  benefited  by  this  drug  in  combination  with 
nux  vomica.  I  have  lately  tried  the  phosphate  of  silver  in  one-third  of 
a  grain  doses,  with  great  success,  and  prefer  it  to  the  nitrate.  In  admin- 
istering the  silver  salts,  it  is  well  to  give  them  continuously  for  several 
months,  and  then  permit  an  interval  to  elapse  before  beginning  again. 
In  the  early  stages  of  the  disease,  I  prefer  the  fluid  extract  of  ergot,  either 
in  combination  with  the  bromide  of  sodium  or  alone.  It  certainly  seems 
to  control  the  pain.  For  this  purpose  a  simple  remedy  often  aflbrds  great 
relief.  If  a  few  drops  of  the  bi-sulphide  of  carbon  are  placed  upon  a 
piece  of  cotton  in  the  bottom  of  a  wide-mouth  bottle,  and  the  same  be 
held  for  a  few  minutes  over  the  painful  spot,  great  ease  will  be  obtained. 
Large  doses  of  salicylic  acid  have  an  anodyne  effect.  Among  the  more 
efficacious  remedies  to  which  I  may  allude  is  the  sulphur  bath,  which  is 
too  little  used  at  the  present  day,  but  has  been  praised  by  the  French 
writers  especially.^     It  seems  to  possess,  in  some  cases,  powers  that  are 

1  Brit.  Med.  Journal,  1875. 

2  Lancet,  1872,  vol.  i.,  p.  437.     . 

3  Gaz.  des  Hop.,  127,  1862. 
^L'Union,  122,  1862. 

5  Bulletin  Gen.  de  Therapeutique,  Ixiii.,  Oct.,  1862. 

^  De  remploi  du  nitrate  d'argent  dans  le  traitement  de  I'ataxie  progressive. 
Bull.  G^n.  de  TMc,  1862. 

''  It  has  acted  wonderfully  in  cases  even  of  long  standing,  and  deserves  a  faithful 
trial. 


340  DISEASES    OF    THE    SPINAL    CORD. 

almost  marvellous.     A  small  lump  of  sulphide  of  potflssiura  is  to  be 
thrown  into  the  tub  in  which  the  patient  bathes,  after  which  he  is  to  be 
thoroughly  rubbed.     In  regard  to  electricity,  xMeyer  has  reported  several 
cures  by  the  galvanic  current.     Onimus  has  used  the  inverse  current, 
and  I  believe  has  done  some  good.     The  indication  seems  to  be  that  the 
positive  pole  should  be  placed  over  the  painful  point,  if  one  can  be  found, 
and  the  negative  above.     These  cases  in  which  cures  have  been  wrought 
were.  I  infer,  ataxic  conditions  of  a  functional  character.     Faradization 
of  the  muscles  of  the  legs  and  thighs  seems  to  comfort  the  patient  more 
than  anything  else.     Duchenue  thinks  that  the  muscular  ausesthesia  is 
benefited  greatly  by  its  use,  and  that  co-ordination  is  improved.     Dr. 
Drinkhard,  of  Washington,^  suggested  that  strychnine  injected  hypoder- 
mically,  is  a  remedy  which  should  not  be  lost  sight  of     In  one  case  it 
promptly  relieved  the  pain.     He,  however,  compares  the  dangerous  ap- 
petite of  possible  formation  to  that  which  grows  out  of  the  medicinal  use 
of  large  doses  of  opium,  and  fears  such  trouble.     I  have  used  the  actual 
cautery  to  the  spine  quite  frequently,  and  have  found  that  constant  re- 
vulsive effect  kept  up  for  some  weeks  not  only  diminished  the  pains,  but 
really  improved  locomotion.    It  should  be  applied  down  the  whole  length 
of  the  back,  on  either  side  of  the  spinous  processes  ;  and,  after  the  epider- 
mis has  shrivelled  off,  subsequent  applications  are  to  be  made.  ^  Belladonna 
and  turpentine  internally  are  recommended  by  Trousseau,  and  not  only 
relieve  the  pain,  but  stem  to  help  any  vesical  trouble  that  there  may  be. 
Should  we  suspect  syphilis,  the  iodide  of  potassium  will  he  indicated,  and 
a  saturated  solution  should  be  prepared,  and  given  in  increasing  doses 
till  forty  or  fifty  grains  are  taken  three  times  a  day.     Above  all,  it  must 
be  remembered  that  nutritious  food,  cod-liver  oil,  and  moderate  stimula- 
tion are  perhaps  more  important  than  medication.     I  have  observed  the 
necessity  for  quiet  and  rest.     Prolonged  muscular  exercise  is  bad,  and 
drives  are  to  be  preferred  to  walking.     The  patient  should  seek  a  warm 
climate,  for  this  disease  is  affected  by  damp,  cold  weather,  very  much  as 
is  phthisis,  and  a  cold  winter  always  tells  upon  the  patient.     The  pains 
also  are  aggravated  by  cold  and  sudden  changes,  and  I  find  Florida  or 
other  southern  states  to  be  the  most  comfortable  places  for  these  inva- 
lids.    Much  benefit  has  been  derived  from  the  dark  room  treatment,  and 
I  saw  one  gentleman  who  had  been  greatly  improved  by  a  few  months  of 
bed-rest  in  a  dark  chamber. 

Nerve-stretching  has  been  tried  in  this  disease  with  some  apparent 
success,  especially  by  Langenbeck  ;  but  though  two  thirds  of  the  reported 
cases  were  helped,  there  was  usually  a  relapse. 

Dissipation  thwarts  any  chance  of  success,  and  late  hours  or  a  debauch 
will  produce  a  relapse  sometimes  after  encouraging  improvtmeut  has 
taken  place.  Sexual  indulgence  (when  it  is  possible)  is  likewise  to  be 
interdicted. 


^  Am.  Jour.  Med.  Sciences,  July,  1873. 


SCLEROSIS    OF    THE    COLUMNS    OF    GOLL. 


341 


SCLEEOSIS  OF  THE  COLUMNS  OF  GOLL. 

(^Ascending  Degeneration  of  Posterior  Columns^ 

The  localization  of  myelitis  in  this  part  of  the  spinal  cord  is  a  matter 
of  great  clifBculty.  Charcot  has  studied  the  appearance  of  degenerative 
changes  in  connection  with  locomotor  ataxia,  and  has  found  that  when 
limited  disease  of  the  columns  of  Goll  was  found,  the  symptoms  were 
those  of  ascending  trouble.  In  his  last  work  (1880)  upon  localiza-' 
tion,  he  has  presented  illustrations  which  show  the  invasion  of  the  disease 
process  and  its  significance. 


(Charcot.) 


A.  Total  sclerosis  of  the  posterior  columns  (columns  of  Goll  and  posterior  root-zones),  ordinary 
locomotor  ataxia. 

B.  Sclerosis  of  the  two  posterior  root-zones  (columns  of  Goll  exempt),  locomotor  ataxia. 
c.  ScIerosi3  limited  to  the  columns  of  Goll — ascending  degeneration. 

Cases  of  degeneration  of  the  columns  of  Goll  are  cited  by  Charcot,^ 
Erb,'  Simon  and  Lange.  In  all  of  those  of  the  first  writer  the  disease 
began  below,  and  in  fact  the  German  investigators  agree  the  disease  begins 
as  a  rule  by  tumors  or  other  forms  of  disease  in  the  region  of  the  chorda 
equina,  and  while  at  this  inferior  part  it  may  result  in  a  quite  transverse 
myelitis,  it  extends  upwards,  being  limited  to  the  columns  of  Goll.  This 
is  beautifully  seen  in  the  upper  part  of  the  cord,  where  the  degeneration 
may  be  well  defined.  The  disease  resulting  from  a  transverse  myelitis 
may  be  transmitted  upwards,  and  degeneration  of  the  columns  of  Goll  be 
found  to  extend  as  far  as  the  floor  of  the  fourth  ventricle. 

Disease  beginning  at  a  higher  level  is  very  apt  to  be  complicated  with 
a  morbid  extension  into  the  adjacent  parts,  so  that  the  appearance  figured 
in  Plate  a  results,  and  this  is  explained  by  the  arrangement  of  commissu- 
ral fibres  found  in  this  part  of  the  cord. 

In  nearly  all  cases  it  is  impossible  to  make  a  diagnosis  between  the 
limited  disease  of  the  posterior  columns  and  that  which  constitutes  true 
"  locomotor  ataxia."     In  the  cases  of  Charcot  and  Pierret  the  symptoms 


1  Lecons  sur  les  localisation,  p.  259,  et  seq.,  Paris,  1880. 
Article  in  Ziemssen's  Cyclopsedia,  p.  773,  vol.  xiii..  Am.  Trans. 


342  DISEASES    OF    THE    SPINAL    0ORI>. 

differ  but  little  from  those  of  the  latter  disease.  It  would  appear  that  the 
success  of  our  diagnosis  should  depend  upon  the  recognition  of  irregular- 
ity in  the  appearance  of  symptoms,  the  absence  of  vertigo  and  ocular 
trouble ;  and  the  predominance  of  other  symptoms  rather  than  the  acute 
pains,  Tvhich  suggest  disturbance  more  of  the  root-zones  than  any  other 
part  of  the  cord.  Pierret^  has  found  the  waist  constricting  band  (parses- 
thesia),  unsteadiness  when  the  eyes  were  closed,  and  impaired  power  of 
preserving  the  equilibrium,  but  none  of  the  striking  symptoms  of  locomo- 
tor ataxia,  in  a  case  of  uncomplicated  disease  of  the  columns  of  GoU. 

ANTERO-LATERAL  SPINAL  SCLEROSIS.^ 

Synonym. — Amyotrophic  lateral  spinal  sclerosis  (Charcot). 

When  the  anterior  tract  of  gray  matter  and  the  latei-al  columns  of  the 
cord  are  conjointly  the  seat  of  the  destructive  changes,  we  find  perma- 
nent contractures  following  loss  of  muscular  power  in  both  upper  and 
lower  extremities,  together  with  extensive  atrophy  and  subsequent  bulbar 
symptoms. 

Symptoms. — The  disease  begins  without  fever  ;  with  loss  of  power 
in  the  muscles  of  the  upper  extremities,  which  becomes  quite  marked 
after  a  short  space  of  time,  and  then  follows  a  general  atrophy  of  the 
muscles  of  the  paralyzed  members.  In  this  way  the  malady  differs  from 
progressive  muscular  atrophy,  in  which  one  group  of  muscles,  or  even  a 
single  muscle,  becomes  atrophied  before  others,  and  in  advance  of  any 
paralysis.  Charcot  calls  this  wasting  process  "  atrophic  en  masse."  At- 
tendant upon  the  paralysis  are  deformities,  and  these  are  highly  charac- 
teristic of  the  disease,  and  result  commonly  from  contractures  of  muscles 
which  are  less  paralyzed  than  others,  so  that  the  stronger  muscles  over- 
come the  weaker.  The  flexors  of  the  hands  are  commonly  affected,  and 
these  members  are  flexed  and  distorted,  the  fingers  being  drawn  up  so 
that  their  ends  press  into  the  palms,  as  is  the  case  in  other  forms  of  post- 
paralytic contractures.  The  arm  may  be  adducted  to  the  side,  and  forci- 
ble adduction  or  extension  is  impossible.  Pain  is  usually  produced  by  any 
violent  effort  made  to  overcome  the  deformity,  and  the  physician  is  obliged 
to  desist.  The  patients  are  able,  though  their  muscles  are  paralyzed  and 
contracted,  to  perform  certain  limited  movements,  but  the  same  tremor  takes 
place  which  we  observe  in  other  forms  of  sclerosis  when  a  voluntary  effort 
of  any  kind  is  made.  In  the  late  stages  the  emaciation  is  complete,  and 
the  appearance  of  the  hands  resembles  that  seen  in  progressive  muscular 
atrophy.  There  are  the  elevated  thenar  eminences  and  the  flat  fore- 
arms, but  the  limb  is  still  contracted.  Charcot  alludes  to  a  condition 
which  sometimes  affects  the  muscles  of  the  neck,  so  that  they  are  con- 
tracted to  such  a  degree  that  the  head  is  fixed  and  immovable.  He  relates 

^  Archives  de  Pliysiologie,  etc.,  1873,  p.  74. 

*  I  prefer  this  compound  title,  as  it  obviates  confusion  and  more  definitely  ex- 
presses the  seat  of  the  disease. 


ANTEEO-LATEEAL    SPINAL    SCLEE0SI9.  343 

a  case  where  the  muscles  of  the  inferior  maxilla  were  so  contracted  as  to 
greatly  interfere  with  mastication. 

The  progress  of  the  disease  is  marked  by  involvement  of  the  tongue, 
and  later  by  the  destruction  of  the  nuclei  of  the  several  cranial  nerves, 
so  that  various  losses  of  special  function  rapidly  follow,  and  death  termi- 
nates the  patient's  sufferings.  The  inferior  extremities  are  paralyzed  in 
their  turn,  and  are  the  seat  of  contractures  which  resemble  in  some  re- 
spects those  of  the  upper  extremities,  so  that  his  condition  is  one 
of  helplessness.  The  legs  become  rigid  when  lie  attempts  to  walk,  and 
are  agitated  by  tremors  so  that  he  is  obliged  to  desist.  The  contrac- 
tures in  the  lower  extremities  are  much  more  marked  than  in  the  upper, 
and  when  finally  the  victim  seeks  his  bed  he  presents  a  most  abject 
and  pitiable  appearance,  the  legs  being  twisted  and  contracted  so  that  he 
requires  the  services  of  an  attendant,  as  he  is  utterly  unable  to  do  any- 
thing for  himself.^  Fibrillary  tumors  may  be  present  just  as  in  progres- 
sive muscular  atrophy,  but  are  not  so  constant  as  in  the  latter  disease. 
The  symptoms  which  usually  herald  the  approaching  end  of  the  disease 
are  those  which  indicate  invasion  of  the  bulb.  Paralysis  and  atrophy  of 
the  tongue,  vermicular  movements  of  that  organ,  and  affections  of  speech, 
are  among  these,  and  the  orbicularis  oris  and  facial  muscles  are  next 
attacked,  when  there  may  be  drooling  of  saliva  and  other  indications  of 
bulbar  degeneration.  In  short,  the  symptoms  are  very  much  like  those  of 
bulbar  paralysis.  Sooner  or  later  the  pneumogastrics  are  implicated,  and 
death  follows.  The  disease  runs  its  course  in  from  six  months  to  three 
years. 

I  have  been  so  fortunate  as  to  see  one  case  of  this  disease,  the  note  of 
which  I  append. 

E.  S.,  laborer.  About  one  year  ago  he  noticed  an  awkwardness  in 
holding  his  spade,  and  when  engaged  in  the  excavation  of  a  cellar  he 
was  unable  to  throw  up  the  dirt,  and  at  the  same  time  felt  unpleasant 
formication  and  cramps.  These  became  so  distressing  that  he  applied 
liniments  to  his  wrist  and  arms,  but  without  any  relief  whatever.  He 
consulted  a  medical  man,  who  tried  electricity,  with  no  good  effect, 
and  after  passing  two  or  three  months  without  treatment,  he  came 
to  me,  and  I  was  able  to  make  a  diagnosis  almost  immediately.  Both 
hands  were  strongly  flexed,  and  the  muscles  were  greatly  atrophied.  The 
index  finger  of  the  left  hand  alone  escaped  contraction.  There  was  some 
rigid  contraction  of  the  forearms,  while  the  arm  was  carried  upwards 
and  forwards  by  the  muscles  of  the  shoulder  and  thorax,  and  there  was 
no  movement  of  the  elbow  or  wrist.  Fibrillary  contractions  were  ob- 
servable in  the  triceps,  pectoralis  major,  and  biceps.  "When  I  endeavored 
to  straighten  the  arm  he  suffered  great  pain,  and  begged  me  to  desist. 
There  seemed  to  be  no  involvement  of  the  lower  extremities,  and  the  pa- 
tient walked  without  embarrassment. 

Seeligmuller  -  saw  several  curious  cases,  which  were  not  only  valuable 

^  There  is  never  cutaneous  ansesthesia,  the  bladder  and  rectum  are  not  affected, 
and  there  is  no  tendency  to  bedsores  (Charcot.) 
*  Deutsche  Medicinische  AYoch.,  April  22  and  29,  1876. 


344  DISEASES    OF    THE    SPINAL    CORD. 

as    instances   of    heredity,   but  ^hich    illustrated    the    course   of    the 

disease.'  ,        „^    ,.        n      •     t  iq-c 

The  cases  came  under  the  observation  of  Seehgmuller  in  January,  18/  b. 
The  family  history,  which  was  carefully  inquired  into,  was  remarkably 
good  with  one  significant  exception— that  the  parents  were  first  cousins. 
There  was  no  evidence  of  syphilis.     Seven   children— six  girls  and  one 
bov— were  the  result  of  the  marriage.     Of  these,  the  eldest,  aged  eleven, 
was  quite  healthy ;  the  second,  aged  ten,  was  in  an  advanced  stage  ot  the 
disease ;  the  third  was,  if  anything,  worse  still,  but  was  not  seen ;  the 
fourth   a  bov,  a^^ed  six  years  and  nine  months,  was  in  the  middle  stage  ; 
the  fifth  and  six'th  were'healthy ;  and  the  seventh,  aged  one  year  and  nine 
months,  was  in  the  first  stage  of  the  affection.     The  disease  began  in  a 
similar  way  in  all.     Strong  and  healthy  when  born,  they  continued  so  up 
to  the  age  of  about  nine  months,  when  a  change  took  place.     Able  pre- 
viously to  sit  up  without  trouble,  they  began  to  lose  this  power,  and 
would  fall  to  one  or  other  side  ;  later,  the  head  and  chest  sank  forward. 
At  the  a<Te  of  two  years  attempts  were  made  to  teach  them  to  walk,  but 
their  efl:'o'rt3  resembled  those  of  an  infant  six  months  old.     This  was  ex- 
emplified in  the  youngest  patient,  who,  when  supported  under  the  armpits, 
made  jumping  movements,  the  legs  being  raised  from  the  ground  simultane- 
ously. Subsequently  the  children  learned  to  support  themselves  with  dith- 
culty  acrainst  a  chair,  but  even  this  power  was  lost  again.   The  boy  had  lately 
been  rapidly  losing  ground  in  this  respect;  he  could  still,  however,  drag 
himself  about  in  his  bed,  and,  by  means  of  a  specially  constructed  chair 
on  wheels,  could  walk.     The  two  eldest  children,  when  supported  in  the 
upricrht  position,  could  not  put  one  foot  before  the  other ;  even  when 
lyinS  down,  they  were  unable  to  move,  the  upper  extremity  being  useless 
as  supports.     The  youn-est  girl  could  sit  for  a  short  time  on  the  table 
but  cried  all  the  time,  a^nd  soon  fell  to  one  side;  she  sat  with  her  head 
and  chest  inclined  forwards,  the  spine  equally  curved,  and  the  thighs 
greatly  abducted  ;  when  on  the  lap,  however,  she  could  move  her  arms 
and  legs  in  all  directions.  _         ,  .  ,    ,  •    .-,     ^-l 

Contractions  at  the  joints  were  present  in  a  high  degree  m  the  three 
eldest.  In  the  eldest  girl  the  hands  were  adducted  and  pronated  ;  pam 
was  produced  by  attempts  at  passive  supination,  and  the  hand,  when  re- 
leased, ierked  back  to  its  old  position.  The  fingers  were  rolled  in  towards 
the  palm,  but  she  could  still  extend  them,  though  very  gradually  and 
with  great  difficulty.  The  grasp  was  still  perceptible  ;  the  right  better 
than  the  left.  The  elbows  were  slightly  bent,  and  nearly  fixed,  ihe 
knees  were  half  flexed,  but  could,  with  great  force,  be  moderatelv  ex- 
tended or  flexed  still  more,  though  on  leaving  them  they  sprang  back 
with  a  jerk  The  feet  were  in  the  position  of  advanced  equiuo-varus ; 
the  tendines  Achillis  were  perfectly  rigid.  All  attempts  at  passive 
movement  produced  considerable  pain.  The  boy  was  put  under  the 
complete  influence  of  chloroform,  and  the  rigidity  of  the  joints  then  so 
increased  that  the  whole  body  could  be  raised  from  one  leg  and  held  out 
like  a  piece  of  wood.     The  youngest  girl  has  so  far  no  contractions. 

Atrophv  of  the  muscles  was  marked  in  the  two  eldest  under  observa- 
tion. Wi'th  the  exception  of  those  of  the  face,  it  was  evenly  spread  over 
the  whole  system.  The  wasting  in  the  case  of  the  girl  was  considerable, 
so  that  the  head  seemed  too  large  for  the  attenuated  neck,  and  was 
moreover  unsteady.     The  parents  were  confident  that  m  all  three  the 

1  London  Medical  Record,  June  15,  1876. 


ANTERO-LATERAL    SPINAL    SCLEROSIS.  345 

wasting  was  not  visible  for  some  time  after  the  loss  of  power  showed 
itself 

In  the  eldest  child  the  reaction  of  the  tibial  and  peroneal  nerves  was 
normal  with  both  currents ;  but  the  irritability  of  the  muscles  was  de- 
cidedly lowered  everywhere.  Of  those  on  the  back  of  the  forearm,  the 
supinator  longus  alone  responded  promptly.  In  the  younge.^t  girl,  fara- 
dic  excitability  of  both  nerves  and  muscles  was  perceptibly  lowered  in  all 
extremities,  but  especially  in  the  left  lower.  Galvanic  excitability  was 
lowered  in  the  same  way,  and  in  the  tibial  nerves  was  almost  nil.  Ordi- 
nary reflex  irritability  not  increased.  That  of  the  tendons,  howev^er,  was 
present  in  a  high  degree  in  all.  Fibrillary  contractions  were  markedly 
present  in  the  eldest  girl,  and  could  be  produced  by  simply  blowing  on 
the  skin.     Sensibility  was  normal  in  all. 

Of  the  symptoms  noticed  by  the  parents,  that  which  made  its  appear- 
ance last  was  the  gradual  loss  of  the  power  of  speech.  Thus,  in  the  two 
eldest  girls,  this  was  tolerable  until  their  sixth  year,  when  it  became  less 
and  less  distinct,  until  finally  only  inarticulate  nasal  noises  could  be  made. 
In  the  girl,  the  lips,  soft  palate,  and  uvula  were  all  paralyzed,  and  the 
tongue  lay  in  the  mouth  like  a  mass  of  dead  flesh ;  its  tip  could  be  ad- 
vanced only  as  far  as  the  teeth.  In  the  boy  the  same  symptoms  were 
present,  but  in  a  somewhat  less  degree.  The  youngest  child  could  say  a 
few  words,  but  these  had  a  slightly  nasal  tone.  Swallowing  in  the  two 
eldest  girls  was  difiicult ;  in  the  boy,  tolerable.  The  form  of  the  skull 
was  unusual  in  all,  but  especially  so  in  the  eldest.  It  was  very  broad 
between  the  parietal  eminences,  and  very  undeveloped  in  the  frontal  re- 
gion. The  forehead  was  low,  and  the  head  appeared  altogether  too  small 
for  the  face.  In  the  eldest  girl  the  features  were  coarse  ;  the  expression 
was  vacant,  but  usually  amiable;  the  pupils  were  much  dilated;  the 
saliva  flowed  continuously  out  of  the  half-opened  mouth  ;  and,  indeed, 
her  general  appearance  was  that  of  an  idiot ;  though,  in  point  of  fact, 
the  intellect  was  very  fairly  developed.  The  faradic  excitability  of  the 
facial  muscles  was  decidedly  increased  ;  the  galvanic  was  normal. 

Causes. — No  definite  causes  are  known,  though  exposure  is  believed 
to  have  much  to  do  with  its  origin,  and  Charcot's  cases  are  thus  accounted 
for ;  but  we  may  also  consider  that  dissipation  and  hereditary  influences 
play  an  important  part  in  the  etiology  of  the  affection.  It  is  a  disease 
which  rarely  occurs  before  adult  life,  so  far  as  we  are  enabled  to  judge 
from  the  limited  number  of  cases  which  have  been  reported. 

Morbid  Anatomy. — To  Charcot  belongs  the  credit  of  having  made 
the  distinction  between  progressive  muscular  atrophy  and  lateral  amyotro- 
phic sclerosis.  Previous  to  1867,  examples  of  this  affection  were  considered 
to  be  cases  of  progressive  atrophy,  which  were  anomalous  in  the  fact  that 
the  lateral  columns  were  affected.  Jaccoud  ^  considers  the  sclerosis  as  circum- 
scribed or  diffused.  Like  sclerosis  in  other  regions,  the  tissue-changes  may 
be  observed  with  the  naked  eye,  either  invading  the  white  or  the  gray 
matter  separately,  or  more  often  together.  In  this  case  the  lesions  are  of 
ancient  date.  The  connective  tissue  is  firm  and  shrunken,  and  the  color  of 
the  hardened  spot  is  gray  or  pinkish-gray.    The  meninges  may  be  adherent 

1  Op.  cit.,  p.  319. 


346  DISEASES    OF    THE    SPINAL    CORD. 

to  the  cord  if  the  sclerosis  be  circumferential,  but  it  is  more  common  in 
uncomplicated  sclerosis  to  find  no  such  change.  The  microscopical  appear- 
ances are  like  those  seen  in  locomotor  ataxia,  as  the  character  of  the  lesion 
is  identical,  the  only  point  of  difference  being  the  location  of  the  tissue- 
change.  Circumi^cribed  sclerosis  is  more  rare  than  the  diffused  variety, 
and  few  cases  have  been  observed.  Of  examples  referred  to  by  Jaccoud, 
in  one  the  lesion  was  confined  to  the  lumbar  enlargement,  and  invaded 
the  entire  anterior  columns  and  a  part  of  the  lateral  columns  ;  and  in 
another,  in  which  the  autopsy  was  made  by  Froramann,^  "  the  sclerosis 
occupied  the  lumbar  segment  and  the  inferior  portion  of  the  dorsal  region. 
It  involved  in  different  degrees  all  the  white  matter,  and  the  gray  was  not 
affected  except  in  the  gelatinous  substance  and  in  the  parts  of  the  poste- 
rior cornua  which  bounded  the  lateral  column."  The  sclerosis  has  in- 
volved the  entire  antero-lateral  columns,  the  anterior  columns  alone,  or  the 
lateral  and  the  lateral  and  posterior  conjointly.  In  diffused  sclerosis,  no- 
dules are  found  in  various  parts  of  the  brain  and  cord,  but  the  predomi- 
nance of  the  sclerosis  in  the  antero-lateral  column  gives  prominence  to  the 
symptoms  which  I  have  described. 

Diagnosis. — It  is  possible  that  this  disease  may  be  confounded  with 
either  progressive  muscular  atrophy,  lateral  sclerosis,  or  spinal  paralysis. 
In  the  first  we  find  a  train  of  symptoms  consisting  of  neuralgic  pains, 
atrophy  of  single  muscles  or  groups,  and  involvement  of  other  muscles 
progressively,  and  secondary  paralysis.  There  are  besides  no  spasmodic 
contractions.  In  lateral  sclerosis  there  is  no  atrophy  beyond  that  result- 
ing from  inaction.  In  the  disease  known  as  spinal  paralysis  the  lower 
extremities  are  generally  affected  first,  and  reflex  excitability  and  electric 
irritability  are  diminished,  which  is  not  the  case  in  the  disease  which  has 
just  been  described. 

Prognosis. — About  as  bad  as  it  can  be,  though  very  few  cases  have 
been  reported.  It  would  seem  that  there  should  be  as  much  chance  in 
this  disease  as  in  lateral  sclerosis,  which  is  sometimes  cured,  but  such  is 
not  the  case. 

Treatment. — I  think  it  may  be  said  that  no  treatment  offers  any 
real  assurance  of  success. 


Anatomie  des  Riickenmarks,  Jena,  186i. 


DISEASES   OF   THE   LATERAL   COLUMNS   OF   THE   SPINAL   CORD.      347 


CHAPTER  XTI. 

DISEASES  OF  THE  SPINAL  CORD— (Continued). 

DISEASES    OE    THE     LATERAL     COLUMNS     OF     THE     SPINAL     CORD. 

The  various  forms  of  disease  of  this  part  of  the  spinal  cord  may  be  ta- 
bulated ■with  reference  to  their  symptom  significance  as:  1.  Infantile 
spastic  paralysis  (spastische  spinallahmiing  of  Erb.^)  2.  Functional 
spastic  paralysis  (Storungen-neurosis  of  Berger.')  3.  Hysterical  spasmo- 
dic paralysis.  4.  ^  Adult  spasmodic  spinal  paralysis  (Primary  symmetri- 
cal lateral  sclerosis  of  Charcot.) 

1.  Is  of  course  an  affection  present  at  birth,  or  commencing  very  soon 
after,  and  has  continued  through  life  in  all  the  cases  so  far  observed. 

2.  Is  not  confined  to  any  age,  but  so  far  the  reported  cases  have  been 
among  adults.  It  has  its  analogue  in  functional  paralysis  and  distur- 
bances of  sensation  dependent  upon  ischsemia  of  other  parts  of  the  cord. 

3.  A  disease  of  adult  life,  and  so  far  has  been  seen  only  among  women. 

4.  A  disease  of  adult  life,  rarely  beginning  before  the  twelfth  year,  and 
sometimes  curable. 

Symptomatology. — The  positive  symptoms  of  lateral  column  disease 
may  be  enumerated  as  paresis,  with  rigidity  and  contractures,  and  in- 
crease of  all  forms  of  reflex  excitability,  and  especially  that  of  the  tendons. 

Of  the  negative  symptoms  we  speak  of  the  absence  of  atrophy,  and 
bladder  and  rectal  complications  as  well  as  true  ataxia,  and  it  may  be 
stated  that  cerebral  symptoms  are  never  present. 

In  the  various  forms  of  lateral  disease,  there  is  great  irregular- 
ity in  the  loss  of  power,  either  in  extent  or  period.  In  the  infan- 
tile cases  it  may  date  from  earliest  life,  and  only  be  recognized  at  the 
time  when  the  child  is  naturally  expected  to  walk ;  or  it  may  gradually 
occur  later  in  life  as  the  initial  stage  of  the  disease.  This  rule  holds 
good  in  every  case  ;  for  in  the  examples  of  secondary  trouble  there  is 
always  an  early  paresis  even,  though  there  may  be  preceding  anaesthesia 

1  Memorab.  Monatsschaft,  f.  r.  p.  a.  xii.  Jahr.  12  H.  1877,  p.  529. 

2  Centralblatt,  1878,  p.  13. 

'  Seguin,  Strumpel  *  and  others  inclined  to  think  that  spasmodic  spinal  paralysis 
may  be  produced  by  a  variety  of  lesions  among  which  are  compression  myelitis,  tumor 
and  cerebro-spinal  sclerosis.  This  is  undoubtedly  true  to  a  certain  extent  but  it  must 
be  acknowledged  that  the  spastic  paralysis  thus  induced  is  seldom  uncomplicated,  and 
that  sensory  and  otlier  irregular  symptoms  are  produced  as  well. 

*  Archiv.  fiir  Psychiatric,  x.  p.  676,  and  xi.  p.  27. 


348  DISEASES    OF    THE    STINAL    COKD. 

or  other  sensory  troubles.  The  early  signs  of  impaired  power  are  manifested 
in  a  variety  of  ways  :  the  individual  easily  tires  ;  and  a  short  walk  produces 
a  sense  of  fatigue  referred  to  in  the  flexure  of  the  knees.  He  leaves 
his  bed  with  difficulty,  and  his  legs  are  used  awkwardly  ;  and  as  the  day 
advances  he  feels  more  disinclined  to  walk  or  move  about.  Should  the 
upper  extremities  be  those  first  affected,  he  finds  himself  unable  to  grasp 
his  tools  as  forcibly  as  be  once  did  If  he  is  a  clerk,  his  pen  is  used 
clumsily  and  its  point  is  not  kept  in  contact  with  the  paper,  but  traverses 
the  lines  unsteadily,  so  that  the  writing  is  exceedingly  tremulous  and 
without  character.  The  paresis  becomes  more  decided,  and  is  con- 
nected with  spastic  rigidity.  Later  on,  as  it  grows  more  profound,  it  re- 
sembles, to  some  extent,  certain  well-known  forms  of  paralysis — but  there 
is  no  anresthesia. 

This  similarity  is  very  decided  in  the  hemiplegic  forms,  but  the  loss  of 
power,  however,  is  likely  to  affect  the  different  members  in  a  decidedly 
irregular  manner,  perhaps  appearing  in  one  leg  first,  then  the  other,  and 
finally  the  arms ;  or  it  may  affect  one  leg,  then  the  arms  of  the  same  side, 
and  then  those  of  the  other  side.  The  limbs  may  be  the  seat  of  paresis, 
which  varies  on  both  sides  in  profundity.  Although  sclerosis  of  tlie  lateral 
columns  on  one  side  only  giving  rise  to  a  hemiplegia  of  spinal  origin  (such 
as  have  been  especially  alluded  to  by  Berger),  may  occasionally  occur,  it 
will  be  seen,  from  an  inspection  of  reported  cases,  that  in  primary  disease 
of  the  lateral  columns,  and  even  in  the  transverse  varieties  of  secondary 
degeneration,  that  the  paresis  is  par aplegi form.  The  paresis  is  suggestive 
of  extensor  paralysis;  and  in  supine  posture  in  the  advanced  stages,  the 
patient  is  usually  unable  to  raise  his  heels  more  than  four  or  five  inches 
from  the  surface  upon  which  he  may  be  lying,  and  in  most  cases  not  even 
to  this  extent.  Combined  with  the  paresis  is  a  certain  amount  of  rigidity, 
which  exists  in  every  case,  and  varies  from  a  simple  spastic  condition  to 
one  attended  by  absolute  contractures.  The  paresis  and  rigidity,  gradual  in 
their  method  of  appearance,  are  rarely  universal ;  but  in  nearly  every  case 
of  either  primary  or  secondary  disease,  ultimately  affect  both  extremities. 
The  earliest  evidences  of  motor  irritation  are  shown  in  the  muscles  of 
the  lower  extremities,  notably  in  a  certain  spastic  stiffness  of  those  of  the 
calf  and  of  the  posterior  and  inner  aspects  of  the  thighs,  and  as  a  result 
of  this  trouble,  there  is  great  rigidity  where  passive  movements  of  the  knee 
and  ankle  joints  are  made ;  and  when  any  attempts  at  locomotion  or  other 
movements  requiring  use  of  the  feet  are  essayed,  these  members  become 
extended  and  quite  rigid.  This  rigidity,  like  the  tendon  reflex,  seems  to 
be  increased  by  warmth  (though  in  a  case  reported  by  Kussmaul  the  reverse 
was  observed),  and  it  is  especially  troublesome  when  the  upright  position 
is  assumed.  When  the  knee  is  bent  and  the  leg  flexed,  it  will  be  found 
that  the  hamstring  tendons  stand  out  as  rigid  cords,  while  there  is  more 
or  less  resistance  to  flexion  of  this  kind.  The  gait  of  patients  suflfering 
from  disease  of  the  lateral  columns,  has  been  called  by  the  Germans 
"  spastichergang  ;"  and  its  peculiarity  depends  upon  the  combination  of 
paresis  and  muscular  rigidity — the  latter  being  increased  by  tke  act  of 


DISEASES   OF   THE  LATERAL   COLUMXS   OF   THE   SPINAL    CORD.     349 

putting  the  foot  to  the  ground.  In  the  beginning,  as  a  result  of  the  loss 
of  power,  the  patient  constantly  stubs  his  toes,  which  comes  in  contact  with 
any  little  elevation  which  may  be  in  the  floor  or  surface  upon  which  he 
walks.  Afterwards  the  embarrassment  is  increased  by  the  spasms  which 
involve  the  muscles  upon  the  posterior  aspect  of  the  leg  ;  and  there  occurs 
a  species  of  talipes  equinus,  the  toes,  however,  being  usually  flexed. 
The  patient,  from  the  first,  walks  with  difiiculty,  his  feet  becoming 
interlocked  and  entangled,  and  through  a  rigid  contraction  of  the  thighs, 
the  knees  are  brought  together  ;  and  as  a  result  of  friction  these  internal 
surfaces  will  be  found  to  be  callous  and  roughened.  The  knees  are  often 
sunken,  so  that  the  anterior  leg  or  thigh  surfaces  form  almost  an  obtuse 
angle,  and  in  the  advanced  forms  of  disease  of  this  kind,  these  deformities 
of  extension  and  adduction  become  very  conspicu^  us,  and  the  patient 
becomes  so  helpless  that  he  requires  a  cane  or  crutches. 

In  the  upper  extremities,  deformities  and  spastic  rigidity  are  neither  so 
markedly  or  constantly  shown,  although  in  rare  cases  terrible  distortions 
of  the  variety  described  by  Charcot^  and  Strauss^  are  sometimes  seen. 

As  a  later  result  of  continued  and  persistent  contractions  of  the  muscles 
ending  in  the  tendo-achillis,  and  in  other  tendons,  there  may  result  condi- 
tions either  of  talipes  equinus,  valgus  and  varus,  and  the  patient's  efforts 
to  walk  cause  him  very  great  distress,  as  his  weight  comes  upon  his  dis- 
torted foot. 

A  peculiar  deformity,  first  noticed  by  Charcot,^  and  which  I  have 
several  times  observed,*  is  the  abdominal  contraction  which  gives  rise  to  a 
very  pronounced  anterior  curvature  of  the  body  ;  and,  as  a  result,  there  is  a 
protrudeut  abdomen  and  a  deep  fissure  below  the  lower  border  of  the  ribs. 
In  such  cases  there  is  usually  some  local  wasting  of  the  muscles  of  the 
back,  just  as  there  would  be  in  any  muscles  subjected  to  disease,  and  kept 
upon  a  stretch  for  a  long  period  of  time,  but  in  no  respect  is  there  true 
atrophy  from  deficient  central  innervation.  The  head  is  never  affected 
by  motor  trouble  ;  and  there  is  no  paresis  of  the  muscles  of  the  neck. 

One  of  the  marked  distinguishing  features  of  disease  of  the  lateral 
columns,  is  an  exaggeration  of  reflex  action  which  is  evinced  in  several 
ways.  Not  only  is  the  skin  reflex  increased  to  a  decided  extent,  so  that 
tickling,  simple  contact  of  the  clothing,  or  even  blowing  upon  the  surface, 
will  provoke  variations  of  motility  of  irregular  and  disorderly  character, 
but  the  "  tendon-reflex,"  which  plays  an  important  part  in  all  these  cases, 
is  excited.  There  are  a  number  of  manifestations  of  motor  irritation 
which  have  been  described  independently ;  but  I  am  of  the  opinion  that 
they  all  resemble  each  other,  and  all  depend  on  activity  of  the  so-called 
"tendon-reflex."  The  so-called  Kaie  or  Uuterschenkel  Phiinomen 
and    Ftiss    Phanomen    of   Erb  and   Westphal,  are  simply  varieties  of 

^Lc9onR  surles  Maladies  du  syst.,  K.,  1872-3. 

^Op.  cit.,  p.  16. 

'  Lepon.'?  sur  les  maladies  du  syst.,  N.  1878. 

*  New  York  Medical  Record,  Oct-  28,  1878,  p.  323. 


350 


DISEASES    OF    THE    SPINAL    CORD. 


chronic  movements  which  follow  forcible  stretching  of  different  tendons 
when  the  knee  and  ankle  joints  are  bent  in  flexion,  and  are  varieties  of 
tendinous  reflex.  The  simplest  and  usually  most  easily  produced  move- 
ments follow  flexion  of  the  foot. 

From  an  inspection  of  a  large  number  of  cases,  I  am  certain  that  the 
value  of  this  test  depends  very  much  upon  the  degree  of  flexion  ;  for  if 
too  little  stretching  of  the  tendo-achillis  is  made,  the  results  will  be  as 
unsatisfactory  as  when  this  tendon  is  over-tensely  drawn. 

To  evolve  this  clonic  movement  (dorsalklonus  of  the  Germans ;  trepi- 
dation provoquee  of  Charcot),  the  operation  is  to  grasp  the  leg  (but  not 
too  tightly)  with  the  left  hand,  while  the  palm  of  the  right  hand  is 
brought  in  apposition  with  the  plantar  surface  of  the  patient's  foot,  which 


Fig.  53. 


is  passively  flexed,  so  that  the  toes 
are  forced  slightly  upwards.  The 
foot  is  kept  in  this  position,  and 
usually  in  a  very  short  space  of 
time,  often  immediately,  there  is 
manifested  a  clonic  spasmodic 
agitation  of  alternate  flexion  and 
extension. 

Sometimes  such  motor  disturb- 
ance continues  after  the  hand  is 
removed,  the  patient's  foot  being 
extended,  the  heel  retracted  by 
the  muscles  uniting  in  the  tendon 
achillis ;  and  while  raised  several 
inches  from  the  floor,  it  is  agi- 
tated for  some  time, — several 
seconds  usually,  but  I  have  seen  cases  in  which  the  trepidation  lasted 
nearly  half  a  minute.  This  trepidation  is  extremely  variable ;  and,  like  the 
movements  following  the  tapping  of  the  tendon,  it  presents  different  features 
in  different  cases  and  at  various  times.  In  some  cases,  it  instantly  follows 
the  original  stimulation,  and  increases  in  frequency,  the  intervals  between 
the  separate  contractions  decreasing,  and  the  muscular  movements  in- 
creasing in  violence. 

In  one  patient  at  present  under  observation,  the  initial  tap  causes  at 
first  an  immediate  but  not  very  violent  kick.  This  is  followed  by  others 
which  increase  in  the  frequency  of  their  appearance  seemingly  as  if  every 
muscular  contraction  arouses  new  collections  of  nerve  force  and  promotes 
the  escape  of  nervous  discharges,  until  finally  as  the  irritability  of  the  cen- 
tral apparatus  becomes  exhausted,  the  contractions  grow  weaker  and  ulti- 
mately cease.  In  some  cases  the  simple  passage  of  the  finger  over  the 
skin  of  the  foot  will  give  rise  to  the  epileptoid  tremor,  and  Joffroy '  has 


Method  of  Provoking  Dorsal  Clonus. 

(GOWERS.) 


Gazette  Medicale  de  Paris,  1875,  Nos.  33-35. 


DISEASES   OF   THE   LATERAL   COLUMNS   OF   THE   SPINAL   CORD.      351 

repeatedly  produced  the  trepidation  by  the  application  of  such  gentle 
excitants  to  the  skin  as  the  contact  of  a  finger-tip  or  a  damp  compress. 

Grasset  ^  reminds  us  that  when  the  patient  is  under  emotional 
excitement,  or  when  he  makes  an  effort  to  execute  certain  move- 
ments ;  or,  again,  when  embarrassed  at  meeting  a  strange  person,  clonic 
spasms  are  sometimes  spontaneously  produced. 

A  variety  of  clonus,  called  by  the  French  "  trepidation  spontanee," 
takes  place  when  no  apparently  affecting  stimulation  is  used.  The  move- 
ments of  a  tremulous  character  which  agitate  the  lower  extremities  of  a 
healthy  person,  who  is  fatigued  after  a  long  walk,  or  some  such  effort,  is 
but  a  simple  illustration  of  the  condition  of  affairs  which  exists  in  dis- 
ease of  the  lateral  columns,  in  a  more  pronounced  degree.  A  constrained 
position,  or  one  in  which  the  tendons  are  slightly  stretched,  is  highly  fa- 
vorable to  the  causation  of  a  paroxysm  of  tremor,  and  where  the  central 
irritability  is  great,  the  mere  contact  of  the  clothing  is  oftentimes  all  that 
is  required  as  a  peripheral  irritation.  The  recumbent  position  and  rest 
seem  to  modify  the  violence  and  frequency  of  these  phenomena ;  for  it 
is  only  in  exceptional  instances  that  they  occur  during  sleep.  As  soon, 
however,  as  the  feet  come  in  contact  with  the  ground,  the  retraction  of 
the  heel  takes  place,  and  every  step  in  walking  is  connected  with  more  or 
less  spasmodic  movement. 

A  form  of  reflex  trouble  which  has  received  but  little  notice,  is  the 
abdominal  reflex.  This  I  have  noticed  in  lateral  disease,  and  I  think  it 
should  be  considered  always  as  a  pathognomonic  sign  of  the  affection. 
When  the  finger  is  passed  ever  so  slightly  over  the  abdominal  parietes, 
there  will  be  a  peculiar,  almost  vermicular  contraction  of  the  underlying 
muscles.  I  have  never  seen  this  sign  absent  in  spasmodic  spinal  paralysis. 
This  excitable  condition  of  the  abdominal  muscles  has  probably  some- 
thing to  do  with  the  curious  action  of  the  bladder ;  and  it  is  probable  that 
the  muscular  fibres  of  this  organ  are  also  subject  to  reflex  spasm  which 
results  in  the  forcible  and  spasmodic  discharge  of  the  urine  which  some- 
times occurs. 

In  certain  cases  the  action  of  the  will  is  capable  of  modifying,  if  not 
stopping,  disorderly  movements  of  a  reflex  nature  ;  but  in  the  great  ma- 
jority the  reverse  is  the  rule,  and  the  attempted  exercise  of  the  volition  is 
frequently  all  that  is  required  to  increase  the  movements. 

In  one  case  I  have  witnessed  a  phenomenon  which  is  not  uncommon  in 
connection  with  the  transmission  of  peripheral  painful  impressions — I  al- 
lude to  delayed  conduction.  In  this  case  the  tap  was  not  immediately 
followed  by  contraction  ;  but  from  three  to  five  seconds  elapsed  before 
any  movement  was  to  be  observed 

In  pure  uncomplicated  disease  of  the  posterior  part  of  the  lateral  col- 
umns there  should  be  no  muscular  atrophy.  In  varieties  beginning  with 
disease  of  other  parts,  or  injury,  such  a  condition  of  affairs  is  possible  but 
not  commonly  seen.     Any  loss  of  muscular  substance  is  simply  due  to 

'^  Maladies  du  Syst.,  n.,  Paris,  1878,  p.  375. 


352  DISEASES    OF    THE    SPINAL    CORD. 

inaction  of  the  limbs,  and  is  of  peripheral  origin,  and  involves  the  entire 
limb.  Bed-sores  are  not  a  feature  of  the  paraplegia,  at  least  not  until  the 
other  parts  of  the  cord  become  involved ;  but  in  the  early  form  of  what 
may  be  a  secondary  local  affection  they  are  sometimes  seen,  as  was  the 
case  in  two  or  three  of  Seguiu's  patients.  In  the  latter  stage  of  primary 
disease  they  do  occur  and  have  been  occasionally  oreerved.  In  no  cases 
have  I  observed  skin  diseases,  arthropathies,  or  other  indications  of  defective 
nutrition.  In  the  confirmed  and  advanced  examples  of  the  disease,  a 
mottled  or  bluish  appearance  of  tiie  extremities  (such  as  is  witnessed  in 
pseudo  hypertrophic  and  infantile  paralysis),  is  quite  common.  This  is 
more  noticeable  when  the  patient's  clothing  is  removed  and  the  skin 
exposed  to  the  air,  when  the  pink  blush  appearing  at  first  gradually 
assumes  a  dusky  hue. 

Although  all  authorities  deny  the  existence  of  any  form  of  sensory 
alteration,  they  nevertheless  prove  by  their  published  cases  that  in  the  ear- 
liest and  last  stage  of  disease  of  this  part  of  the  spinal  cord,  various  sensory 
phenomena  are  presented.  For  instance,  in  seven  out  of  twelve  cases  of 
primary  disease  of  the  lateral  columns,  there  were  either  pains,  anaesthe- 
sia, or  light  forms  of  surface  hyperesthesia.  "  Tingling,"  or  "  burning  " 
sensations,  dragging  pains,  "  pricking,"  or  "  numbness  "  are  spoken  of, 
and  probably  arise  from  some  irritation  of  the  posterior  nerve  roots. 

It  may  be  stated  positively  that  absence  of  anything  like  sensory  dis- 
turbances, such  as  are  found  in  other  spinal  diseases,  is  the  rule  ;  but  it 
cannot  be  denied  that  an  occasional  or  early  diminution,  or  more  com- 
monly, elevation  of  the  cutaaeous  sensation,  is  a  feature  of  affections  of 
this  kind. 

In  the  .secondary  disorders,  where  perhaps  a  congestion  of  the  posterior 
columns  is  the  primary  marked  process,  or  where  pressure  m  made  by 
some  growth,  or,  by  a  diseased  vertebra,  or,  as  is  sometimes  the  case,  by 
the  products  of  inflammation  in  meningitis,  there  must  be  more  or  less  dis- 
turbance of  sensation.  In  special  varieties  this  is  decided,  and  where 
associated  with  hysteria  it  is  not  unreasonable  to  expect  to  find  anaesthe- 
sia; but  unlike  the  impaired  sensation  in  true  spinal  disease,  it  is  iri'egu- 
larly  distributed,  and  often  associated  with  ovarian  hypersesthesia. 

In  one  of  the  cases  repi)rted  by  Seguin  there  was  anaesthesia,  probably 
the  result  of  injury  of  nerve  tracts  other  than  the  lateral  columns,  but  as 
in  other  cases  the  symptoms  of  Ideral  disturbances  predominated. 

Tactile  sensibility  seems  to  be  in  no  way  affected  ;  and  appreciation  of 
heat  and  cold  are  usually  normal,  except  in  advanced  stages,  when  sub- 
jective cold  is  complained  of. 

There  are  never  any  indications  of  paresis  of  the  bladder  or  rectum. 
Constipation  is  not  usual;  and  if  there  is  any  bladder  trouble  it  is  one 
of  a  sthenic  nature,  and  accompanied  by  spasmodic  ejection  of  the  urine. 

The  patient  is  quite  able  to  stand  with  his  eyes  closed,  before  his  loss 
of  power  renders  him  helpless — and  he  can  co-ordinate  properly.  The 
only  exception  to  this  rule  is  when  the  disease  has  involved  the  posterior 
columns,  as  in  the  complicated  cases  mentioned  by  Erb. 


DISEASES    OF    THE   LATERAL    COLUMNS    OF    THE   SPINAL    CORD.    353 


CONGENITAL  IMPERFECT   DEVELOPMENT   OF,  OR   DEGENERATION   OF   THE 

LATERAL  COLUMNS  OF  THE  SPINAL  CORD,      INFANTILE 

FORM,   "SPASTISCHE    SPINALLAHMUNG  BIE 

KLEINEN    KINDERn"    OF    ErB. 

The  subject  of  spasmodic  spinal  paralysis  of  infancy  has  received  but 
passing  notice,  and  a  contribution  of  Erb's^  is  the  only  description 
to  be  found  of  the  disease  which  is  an  analogue  of  adult  spastic 
paralysis  of  the  primary  form.  Four  cases  were  presented  by  this 
observer,  two  of  which  were  described  in  his  second  article'^  in  Vir chow's 
Archives ;  and  two  others  are  detailed  in  the  communication  before  re- 
ferred to. 

I  have  seen  several  cases  which  are  clearly  marked  examples  of  spastic 
infantile  paraplegia.  Several  of  these  cases  have  also  been  observed  by 
others,  but  not  recognized  and  described  as  lateral  column  disease,  and 
in  more  than  one  case  the  disease  has  been  regarded  as  the  result  of 
preputial  irritation  from  phimosis. 

The  paresis  is  usually  not  recognized  until  a  year  or  so  after  birth, 
when  the  child  should  walk,  but  does  not  do  so ;  and  in  such  cases  the 
ailment,  as  Erb  has  pointed  out,  has  too  often  been  mistaken  for  infantile 
palsy  or  some  such  common  disease  of  early  infancy.  If  this  error  is  not 
made,  ante-natal  cerebral  hemorrhage  or  spinal  traumatism  is  generally 
supposed  to  account  for  the  paralysis.  One-sided  brain  atrophy,  such  as 
has  been  alluded  to  by  Taylor,^  produces  a  hemiplegic  condition  with 
contractures,  exalted  tendon-reflex,  etc. ;  but  cerebral  symptoms  of 
greater  or  less  importance  are  added  thereto. 

Finally,  it  has  been  the  fashion  of  late  to  ascribe  all  the  trouble  to  an 
irritated  and  phimosed  prepuce.  Circumcision  has  even  been  tried  in 
many  instances ;  but  the  rigidity  and  paresis  have  remained  the  same, 
for  in  all  of  these  cases,  the  trouble  was  far  beyond  the  surgeon's  knife. 

In  this  form  of  disease,  or  congenital  partial  absence  of  the  lateral  col- 
umns, the  contractures,  according  to  Erb,  make  their  appearance  at  a 
very  early  age.  In  one  of  the  patients  I  have  seen,  the  limbs  are  as 
rigid  at  the  age  of  seven,  as  they  would  be  in  the  advanced  stage  of 
this  disease  in  an  adult ;  and  in  such  a  condition,  I  understand,  they  have 
been  since  the  third  year. 

This  early  development  of  contractures  is  ascribed  by  Erb  to  the  im- 
perfect voluntary  power  which  belongs  to  childhood,  which  prevents  ,the 
little  patients  from  exercising  or  resisting  the  advance  of  the  deformity. 

Subjective  coldness  is  noticed,  and  the  cutaneous  circulation  is  sluggish, 
so  that  the  limbs  have  a  mottled  appearance.  The  ability  to  speak 
seems  to  be  impaired — not  from  a  condition  of  mental  weakness,  however, 
for  the  mind  of  many  of  these  children  is  quite  active ;  but  there  appears 
to  be  both  a  local  awkwardness  and  a  disinclination  to  talk.     Unless  the 

Op.  cit.        2  Virchow's  Archiv.,  B.  70,  1877,  p.  293.         =*  Guy's  Hosp.  Eep.,  1878- 
23 


354  DISEASES    OF    THE    SPINAL     CORD. 

patient  is  held  upright,  he  is  quite  unable  to  walk  alone,  for  there  is 
crossing  of  the  legs,  and  adduction  of  the  thighs.  If  a  determined 
effort  is  made  to  walk  (he  being  supported  meanwhile),  the  feet  will 
be  drawn  into  the  position  of  talipes,  and  his  toes  will  catch  the  ground 
at  every  step.  The  disposition  is  for  the  feet  to  be  drawn  across  each 
other,  so  that  in  an  extended  position,  one  foot  covers  its  fellow,  and  so 
they  remain.  When  laid  upon  the  bed  the  legs  and  thigh  are  sometimes 
drawn  up  and  agitated  by  clonic  movements.  In  severe  cases  the  loss 
of  power  is  so  great  that  (as  in  adult  cases)  the  patient  cannot  lift  his 
feet  or  raise  his  legs.  ^ 

No  sensory  disturbances  are  complained  of;  and  in  but  one  of  Erb  s  cases 
was  there  any  symptom  of  this  kind,  and  that  a  slight  hyper^esthesia.  Skin 
and  tendon  reflexes  are  increased.  Bladder  and  sphincter  ani,  normal. 
Cerebral  symptoms,  nil. 

A  curious  fact  appears  to  be  established,— and  this  is,  that  in  three  of 
the  seven  cases  I  have  collected,  the  children  were  prematurely  born ; 
and  I  think  great  importance  of  a  pathological  kind  must  be  attached  to 
such  a  state  of  affairs. 


II. 

FUNCTIONAL    DISEASE   OF   THE    LATERAL    COLUMNS. 

The  recently  reported  case  seen  by  Kussmaul  ^  is  an  example  of  this 
kind ;  for  the  favorable  results  obtained  by  him  were  highly  suggestive 
of  such  a  conclusion.  Berger'  has  also  seen  a  case;  and  I  have  no 
doubt  but  that  many  of  the  cases  of  spasmodic  troubles  of  the  lower  ex- 
tremities, known  heretofore  as  "  functional  spasms,"  are  after  all  only 
varieties  of  ischcemia  of  the  lateral  columns. 

In  Hanfield  Jones'  work,'  I  find  reference  to  a  case  reported  by  Baum- 
berger,  which  is  as  follows  : — 

The  patient  was  a  youth,  19  years  of  age,  who  during  convalescence 
from  pneumonia,  began  to  suffer  with  a  spasmodic  affection  of  the  lower 
extremities.  "  As  soon  as  he  touched  the  ground  with  his  feet,  all  the 
muscles  of  the  lower  extremities  fell  into  a  state  of  tetanic  rigidity,  inter- 
rupted by  the  most  violent,  sudden  contractions,  which  threw  the  patient 
upwards ;  and  during  their  rapid  recurrence  increased  in  intensity,  so 
that  the  patient  had  to  be  supported.  At  the  same  time,  the  face  was 
flushed  and  distorted,  the  pulse  accelerated  and  extremely  feeble.  The 
moment  that  the  patient  sat  or  laid  down,  all  the  movements  ceased.  If, 
while  lying  in  bed,  the  soles  of  his  feet  were  pressed,  the  same  phenomena 


1  Berliner  Klin.,  TVochenschrift,  Sept.  23,  1877. 

2  Abst.  in  Centralblatt,  July  13,  1878  . 

3  Schmidt's  Jahrsbericht,  vol.  cij.,  pp.  23-4,  and  H.  Jones  on  Functional  Nervous 
Disorders,  p.  398. 


DISEASES   OF   THE   LATERAL   COLUMNS   OF   THE   SPINAL    COED.       355 

appeared,  but  with  much  less  intensity."     He  was  cured  by  sedatives  and 
cold  affusions. 

In  the  interesting  case  reported  by  Kussmaul,  complete  recovery  took 
place  within  less  than  one  year. 


III. 

HYSTEEICAL    SPASMODIC  SPINAL  PARALYSIS. 

The  celebrated  case  reported  by  Charcot  of  hysteria,  in  which  the  four 
extremities  were  contracted,  is  one  which  illustrates  a  form  of  disease  of  the 
lateral  columns  occurring  as  an  outgrowth  of  the  neurosis  which  is  so 
commonly  thought  to  be  a  purely  functional  affection.  This  and  other 
cases  are  so  well  marked,  however,  and  present  such  unmistakable  symp- 
toms of  both  diseases  that  I  think  a  hysterical  variety  of  spasmodic  sjiinal 
paralysis  may  be  recognized. 

lu  all  of  the  cases  to  which  I  shall  refer,  it  is  probable  that  the  primary 
disease  was  purely  peripheral,  and  as  a  central  degeneration  has  been 
known  to  occur  after  section  of  important  nerve  trunks  there  is  no  reason 
why  we  should  not  with  perfect  reason  recognize  the  same  pathologi- 
cal origin  in  cases  where  long  existing  hysterical  paralysis  has 
been  connected  with  a  more  than  ordinary  inactivity  and  disuse  of  a 
member.^ 

Charcot,  in  his  early  fasciculus,  (1872-3),  goes  quite  extensively  into  the 
question  and  describes  the  "  tremulation  convulsive,"  and  other  symp- 
toms. He. says:  "Quelle  condition  est  done  survenue  et  a  entretenu 
ainsi  I'existence  de  cette  paraplegie  avec  rigidite  des  membres  ?  Evidem- 
ment,  dans  les  cas  rdcents  de  contracture  hystdrique,  la  modification  or- 
ganique,  quelle  quelle  soit,  quelque  si^ge  qu'elle  occupe,  qui  produit  la 
rigidite  permanente,  est  tres-legere,  tres-fugace  puisque  les  symptomes  qui 
lui  correspondent  peuvent  disparaitre  tout-a-coup,  sans  transition,  *  *  *  * 
il  s'est  produit,  a  une  certaine  epoque,  une  Idsion  scldreuse  des  cordons 
lateraux,  lesion  que  la  ndcroscopie  permettrait  actuellement  de  recon- 
naitre." 

Briquet  has  seen  cases  of  paraplegia  complicated  with  contractures, 
and  mentions  three  examples.  In  these  cases  there  was  pain  and  rigidity, 
especially  when  passive  movements  were  attempted.  One  of  his  cases 
afterwards  fell  into  Charcot's  hands,  and  is  that  of  which  we  have 
spoken. 

The  development  of  symptoms  indicative  of  lateral  column  disease  is 
rarely  an  early  feature,  and  in  the  reported  cases  there  was  a  primary 
hysterical  paralysis  which  had  lasted  some  years,  when  the  first  indica- 
tions of  the  degeneration  of  the  lateral  columns  were  shown  in  an  in- 
crease in  all  the  reflexes,  and  an  increase  of  the  rigidity  of  the  contrac- 
tured  limbs. 

^  Traite  clinique  et  therapeutique  de  1'  hysterie.      Paris,  1859. 


356  DISEASES    OF    THE    SPIXAL    CORD. 

In  more  than  one  of  Richter's'  cases  there  was  a  decided  hysterical 
element,  but  this  was  not  exhibited  before  the  more  important  special 
symptoms  had  shown  themselves. 

IV. 

PRIMARY  DEGENERATION  OF  THE  LATERAL  COLUMNS. 

(Tabes  Dorsalis  SpaHmodique,  Spasmodic  Spinal  Paralysis,  Lateral  Spinal 
Paralysis)    Tetanoid  Paraplegia  {Seguin). 

The  disease  which  by  Charcot  has  been  supposed  to  be  essentially  a 
sclerosis  of  the  lateral  columns  of  the  spinal  cord,  though  in  such  a  con- 
clusion he  has  not  been  supported  by  Erb,  has  been  called  by  the  former 
"Tabes  dorsalis  spasmodique,"— and  by  Erb,  "spasmodic  spinal  par- 
alysis." 

With  the  exception  of  the  few  infantile  cases  already  referred  to, 
which  I  do  not  believe  to  be  always  identical  with  those  in  which  the 
disease  begins  later  in  life,  so  far  as  pathology  is  concerned,  the  reported 
cases  have  all  been  among  adults.  In  the  cases  so  far  observed,  the 
beginning  of  the  disease  lias  been  singularly  slow  and  insidious.  There 
has  been  no  febrile  stage,  and  absolutely  none  of  the  early  and  sudden 
symptoms  which  attend  the  development  of  many  of  the  spinal  paralytic 
diseases ;   but,  on  the  contrary,  the  appearance  of  symptoms  has  been 

very  gradual.  •   •  •  i 

In  most  of  the  cases  brought  forward,  there  have  been  initial 
symptoms  of  a  sensory  character,  although  few  of  them  have  been  more 
than  irregular  and  fugitive.  Dragging  pains  in  the  hips  and  down  the 
back  of  the  thighs,  pain  in  the  back,  and  sometimes  hyperesthesia  of  no 
very  lasting  or  severe  kind,  enter  the  list. 

In  Erb's'  cases  (16  in  number),  seven  presented  sensory  symptoms 
in  the  first  stage.  In  six  the  pain  was,  without  doubt,  due  to  spinal  irri- 
tation ;  and  in  the  other  cases  there  was  a  doubt  in  favor  of  articular 
rheumatism.  There  were  various  transitory  and  ill-defined  pains,  formi- 
cations in  the  fingers  and  soles,  and  subjective  cold.  In  Schulz's'  paper, 
other  cases  with  such  initial  symptoms  are  mentioned.  Charcot,  *  how- 
ever, does  not  believe  in  the  existence  of  pains  during  the  first  stage,  and 
a  few  other  authors  agree  with  him  ;  but  in  the  German  and  American 
examples  of  this  disease,  so  far  reported,  there  is  ample  reason  to  believe 
in  their  existence  in  about  one-half  of  the  number  of  cases.  These 
sensory  troubles  usually  last  for  a  few  months,  and  may  be  coincident 
with  the  appearance  of  muscular  weakness,  such  as  has  been  described 
under  another  head. 


1  Deutsches  Archiv.  fiir  Klin,  Med.  18,  6,  p.  365. 

2  Virchow's  Archiv.,  Bd.  Ixx.,  H.  2,  page  24,  et  seq. 

3  Archiv.  der  Heilkunde,  1877,  page  352. 

*  LeQons  sur  les  Malad.  du  syst.,  N.  4'"«-  fascic,  page  279. 


DISEASES   OF   THE   LATERAL   COLUMNS   OP   THE  SPINAL   CORD.      357 

Patients  who  are  in  the  advanced  stage  of  the  disease  present  in  addi- 
tion to  great  loss  of  power,  contractures  of  advanced  development ;  and, 
as  a  consequence,  there  is  deformity  which  is  always  quite  prominent. 

As  to  the  loss  of  power,  it  will  be  noticed  that  in  nearly  all  the  reported 
cases  the  lower  extremities  were  affected  in  the  beginning,  although  it 
is  not  rare  to  find  either  hemiplegic  cases,  or  those  beginning  on  one  side 
and  afterward  involving  the  other,  this  extension  occupying  a  long 
period  of  time.  Again,  the  upper  extremities  are  sometimes  affected  first ; 
but  these  cases  are  extremely  rare,  and  I  can  find  but  two  mentioned.     It 


Fig.  54. 


Contraction  of  feet  in  an  advanced  ease  of  primary  degeneration  of  the  Lateral  Columns. 

however  follows  that  when  loss  of  power  begins  below,  the  arms  are 
quite  likely  to  be  affected ;  so  that  the  contractures,  trepidations,  and 
all  the  symptoms  already  shown  below  are  likely  to  appear  in  the  upper 
extremities  after  two  or  three  years.  Even  the  muscles  of  the  trunk,  as 
shown  in  one  of  my  cases,  are  finally  implicated. 

Betous  makes  the  third  stage  of  the  disease  include  general  contrac- 
tures of  the  upper  and  lower  extremities  and  trunk  muscles.  The  loss  of 
power  can  hardly  be  called  an  absolute  paralysis,  for  the  paresis  is  un- 
equal, and  the  patient  possesses  for  a  long  time  a  great  deal  of  ability  to 
perform  certain  actions  with  a  great  deal  of  ease,  while  others  are 
impossible. 

Motor  irritation  is  a  feature  of  the  second  stage  of  the  disease,  and  ac- 
companies the  paresis.  The  first  indication  of  stiffness  marks  the  appear- 
ance of  this  symptom,  and  a  variety  of  irregular  disorders  of  motility 
follow,  such  as  twitching  of"  the  feet,  tremor  amounting  almost  to 
clonic  spasms  when  the  toes  are  allowed  to  touch  the  floor,  and  rigidity. 
when  passive  movements  are  made,  then  other  phases  of  excitement  in 
muscular  action  are  exhibited  in  different  degrees,  and  at  different  times 
until  the  disease  has  run  an  extended  course.  I  have  found  that 
in  some  old  cases  the  clonic  movements  following  excitation  are  not  so 
active  as  in  the  early  stages,  but  that  spastic  rigidity,  and  contractures 
apparently  uninfluenced  by  any  ordinary  excitation,  exist ;  and  also  that 
there  is  no  apparent  increase  of  rigidity  in  connection  with  the  excita- 
tion of  any  special  movements. 

As  to  the  negative  symptoms  of  the  disease,  there  is  little  to  be  added 


358  DISEASES    OF    THE    SPINAL    CORD. 

more  than  what  has  been  stated  in  speaking  of  general  symptomatology. 
It  may  be  said,  however,  that  there  is  no  impairment  of  the  sexual 
powers. 

The  disease  ultimately  reaches  a  stationary  period ;  and  unless  there 
be  a  subsequent  acute  myelitis  Avhich  ascends  and  involves  the  bulb,  the 
patient  is  likely  to  live  for  years,  finally  to  die  from  an  intercurrent 
disease.  After  the  stationary  period  is  reached  he  is  perhaps  helpless,  and 
is  confined  to  his  bed.  His  contractures  may  become  painful,  and  in  gene- 
ral his  health  suffers  through  inaction  and  want  of  exercise. 

In  some  cases  the  attempt  to  stand  is  attended  with  great  suffering,  as 
the  toes  are  flexed  ;  and  when  the  entire  weight  of  the  body  is  thrown  on 
them  in  this  constrained  position,  the  patient  is  often  unable  to  progress 
even  with  the  aid  of  a  stick  or  crutches  without  great  agony. 

I  have  noticed,  in  connection  with  the  other  symptoms  in  two  of  my 
cases,  a  great  deal  of  emotional  disturbance,  which  at  times  amounted 
to  hysteria ;  and  I  am  inclined  to  believe  that  this  is  but  another  illustra- 
tion of  the  appearance  of  sysmptomatic  hysteria  in  connection  with 
organic  nervous  disorders,  such  as  has  been  clearly  described  by  Charcot, 
S^guin  and  others. 

Causes. — The  causes  of  disease  of  the  lateral  columns  are  but  little 
known,  if  we  may  put  out  of  the  question  such  mechanical  factors  as  ex- 
ternal disease  or  pressure,  such  as  are  found  in  secondary  degeneration. 

A  reference  to  some  of  the  forms  of  trouble  spoken  of  in  other  pages  is 
all  that  may  be  necessary  under  this  head  (I  allude  to  the  hysterical  and 
infantile  forms).  In  the  first,  I  think  there  can  be  no  doubt  as  to  the 
origin  of  the  affection  as  its  name  implies ;  while  in  the  other  there  are 
actual  cavities  in  the  cord  ;  degeneration  with  syringo-myelia  or  non- 
closure of  the  central  canal ;  or  imperfect  formation  of  the  lateral 
columns. 

In  such  cases,  there  seem  to  be  no  hereditary  influences  to  explain 
their  origin  except  perhaps  consanguineous  marriages ;  and  we  arrive 
at  about  the  same  result  when  we  attempt  to  trace  back  influence 
of  this  kind  in  cases  of  cleft-palate,  hair-lip,  and  congenital  deformities  of 
other  kinds. 

In  one  of  Erb's  cases  occurring  in  infancy,  the  fact  that  five  other 
children  in  the  same  family  were  born  before  full  term,  is  suggestive  of  a 
tendency  to  non-development.  In  Richter's  four  adult  cases,  there  was  a 
history  of  insanity  on  the  father's  side  in  two  cases,  and  sclerosis  in  a 
third. 

An  infantile  case  is  reported  by  Berger,  in  which  the  disease  followed 
an  attack  of  diphtheria ;  but  this  is  the  only  infantile  or  adult  case  in 
which  I  can  find  such  a  complication,  except  one,  a  man  who  had  scarlet 
fever  in  early  life,  which  was  the  beginning  of  his  serious  trouble.  The 
lateral  columns  of  the  spinal  cord  are  rarely  the  seat  of  primary  dis- 
ease until  after  the  twentieth  year, — although  Erb  has  reported  the 
disease  in  a  girl  of  sixteen.  In  hysterical  cases,  even,  the  primary 
paresis   and   contractures  rarely  appear   before   several   years   of    hys- 


DISEASES   OF   THE  LATERAL   COLLTMXS   OF   THE  SPIKAL   CORD.      359 

terical  paralysis  have  passed.  In  one  of  my  cases  the  disease  was  estab- 
lished at  twenty-two  ;  and  in  none  of  Charcot's  cases  did  the  affection 
appear  before  adult  life.  In  secondary  disease,  there  is  no  regularity  in 
the  question  of  age.  I  think  in  the  extra-spinal  form,  childhood  is  the 
period  when  we  may  expect  the  causation  of  such  troubles  ;  while  if  there 
be  tumors,  effusions  of  blood,  or  meningeal  disease,  there  can  be  no  in- 
fluence referred  to  age. 

The  ages  of  all  the  patients  with  primary  disease  (spasmodic  tabes), 
whose  histories  I  can  gain  access  to,  are  the  following : — 


Between    15    and   20 2 

20       "30 8 

"        30      "40 15 


As  to  the  occupation  of  these  patients,- 


reel 

1  40  and    50 

.    .      9 

(( 

50     "       60  

.    .      3 

Total  .    . 

.    .    37 

3    . 

.   were     . 

.    laborers. 

2    . 
2    . 
1    . 
1    . 

.    were     . 
.    were     . 
.    was  a   . 
.    was  a   . 

.   peasants. 
.    tradesmen. 
.    barber. 
.   teacher. 

1    . 

.    was  a   . 

.    car-driver. 

1    . 

.    was  a   . 

.    silversmith 

shoemaker. 

painter. 

printer. 

butcher. 

carpenter. 

clerk. 


and  in  twenty  cases  the  occupation  was  not  stated. 

Of  these  patients  22  were  men,  and  15  women.  In  fact,  the  disease  is 
not  so  common  among  women,  and  in  many  of  the  cases  there  was  an 
hysterical  element,  notably  so  in  the  case  of  the  Princess  F.,  reported  by 
Erb.  In  one  of  his  articles  he  refers  to  the  fact  that  the  disproportion  in 
sex  is  not  so  great  as  in  locomotor  ataxia.  Climatic  influence  has  been 
alluded  to  :  in  fact  the  singular  circumstance  that  a  number  of  Erb's  cases 
were  from  Eheinish  Bavaria  led  him  to  think  that  there  was  some 
endemic  influence;  but  the  subsequent  recognition  of  cases  in  all  parts 
of  the  world  proves  the  contrary. 

In  one  case  reported  by  Betous  and  another  by  myself,  the  patients 
were  metal  workers ;  but  at  least  in  one  of  these  cases  there  were  other 
causes;  so  the  theory  of  metallic  poisoning  must  fall  to  the  ground. 
Syphilis  has  not  entered  into  the  history  of  the  cases;  and  Erb 
does  not  think  it  has  much  influence  in  the  production  of  the 
disease.  "  Damp,  humid  cold,"  in  the  experience  of  Charcot,  who  has 
seen  five  cases,  has  existed  as  a  cause ;  and  in  many  cases,  exposure 
to  rain,  excessive  venery  or  dissipation  have  played  parts  in  the 
development  of  the  disease.  So  little  is  known  in  regard  to  the 
genesis  of  all  forms  of  sclerosis,  that  any  attempt  to  solve  the  problem 
must  be  speculative.  I  believe  that  locomotor  ataxia  (and  probably 
the  disease  in  question)  is  undoubtedly  due  to  what  is  at  first  but  an 
ischsemic  spinal  state.     In  certain  individuals  of  sedentary  habits  and 


560 


DISEASES    OF    THE    SPINAL    COED. 


nervous  temperament,  occasionally  the  victims  of  the  gouty  vice,  the 
cord  is  subject  to  sudden  modifications  in  circulation,  and  consequenily 
in  nourishment,  and  as  a  result  a  condition  of  "  spinal  irritation  "  in  the 
primary  trouble  which  may  depend  upon  anaemia  on  the  one  hand,  or 
unequal  congestion  on  the  other ;  and  as  a  result  of  such  changes  a  hyper- 
trophy of  the  connective  tissue  follows,  which  constitues  the  sclerosis. 

Pathology  and  Morbid  Anatomy.  —  The  proper  discussion 
of  the  genesis  of  congenital  spastic  paralysis  would  involve  an  extended 
consideration  of  the  development  of  the  spinal  cord,  which  would  be  out 
of  place  in  a  text  book.  The  existence  of  anomalies  in  the  cord,  such  as 
have  been  described  by  Ollivier,  Longet,  Goll,  Calmeil,  Charcot,  Leyden 
and  others^  under  the  head  of  Syringo-myeUa  and  hydromelia  viWl  explain 
development  of  early  disease  of  the  lateral  columns.  Leyden'-  has  minutely 
described  the  openings  found  especially  in  the  posterior  columns  as  the 
result  of  myelitis. 

In  Leyden's  cases  the  cavities  which  were  the  result  of  disease  during 
fcetal  life  were  characterized  by  great  unevenness  of  contour,  by  splitting 
up  of  the  opening  into  others,  or  bye  ertain  indefinite  and  irregular  varia- 
tions, while  the  canals  due  to  the  absence  of  tissue  incident  to  arrest  of 
development  were  of  symmetrical  configuration;  and  the  cord  rarely  pre- 
sented any  evidence  of  general  disease,  such  for  instance  as  sclerosis. 

As  to  the  arrest  of  development  of  the  cord  and  the  consequent  abnor- 
mality in  the  lateral  column  function,  we  must  take  into  account  the  fact 
of  the  existence  of  the  transverse  fissure  alluded  to  by  Charcot  and  others, 
among  them  Waldeyer.  It  is  probable  that  the  infantile  forms  of  lateral 
column  disease  therefore  are  due  either  to  some  imperfect  closure  of  the 
lateral  column  or  a  sclerosis  beginning  during  uterine  life. 

Fis.  35. 


(Leyden.) 


1.  Syringomyelia.    2.  3.  Hydromyelia.    a.  a.  Lateral  fissures  and  imperfect  development  of 
lateral  columns. 

Flechsig,'  in  an  elaborate  article,  has  written  extensively  upon  the  con- 
nection of  certain  fibers  in  the  lateral  columns,  with  cells  in  the  anterior 


1  See  Prize  Essay  of  American  Medical  Association  upon  Primary  and  Secondary 
degeneration  of  the  Lateral  Columns  of  the  Spinal  Cord,  1S79,  by  the  author. 

2  Virchow's  Archives,  Bd.  68,  Oct.  9,  1876. 
'Archiv.  der  Heilkunde,  1877-1878. 


DISEASES   OF   THE   LATERAL   COLUMNS   OF   THE   SPINAL   CORD.      361 

gray  horns  and  Clarke's  columns  and  certain  fibers  of  the  crossed  pyra- 
midal columns  evidently  arise  from  large  cells  in  the  anterior  parts  of 
the  anterior  horns,  and  these  are  supposed  by  him  to  be  concerned  in  the 
provision  of  peripheral  motor  power,  and  to  be  involved  when  there  are 
contractures.  Fig.  56  will  enable  the  reader  more  fully  to  study  his  ar- 
rangement. 

(Fig.  56.) 


(Flechsig.) 

T.  C.  Column  of  Turck.  C.  G.  Column  of  Goll.  C.  L.  Clarke's  column.  1.  Fibers  in 
cerebellar  column  connecting  with  Clarke's  column.  2.  Connection  of  crossed  pyramidal  fibers 
with  gray  matter.    3.  3.  Connection  of  fibers  of  anterior  column  with  cells  of  anterior  cornua. 

Gray^  says  that  he  is  not  prepared  to  accept  Flechsig's  views  in  their 
entirety,  because  he  believes  that  disease  of  the  crossed  pyramidal  columns 
is  not  always  associated  with  contractures,  and  brings  forward  a  case  re- 
ported by  Shaw  in  refutation  in  which  the  morbid  processes  involved  the 
crossed  pyramidal  columns,  and  still  this  symptom  did  not  occur 

The  numerous  cases  of  secondary,  degeneration  after  cerebral  disease, 
in  which  contractures  of  the  most  formidable  and  conspicuous  kind  were 
manifested,  and  in  which  all  degrees  of  degeneration,  partial  and  com- 
plete were  observed,  would,  however,  rather  neutralize  the  value  of  a 
single  exceptional  case ;  and  such  have  been  frequently  reported. 

The  experiments  of  Woroschiloff  ^  on  animals  have  shown  that  the 
lateral  columns  of  the  cord  contain  motor  and  sensory  fibers,  which  are 


^  Transactions  of  Kings  Co.  Medical  Society. 

^  Ludwig's  Arbeiten,  1875.     Abstract  in  Journal  of  N.  and  M.  Diseases. 


362  DISEASES    OF    THE    SPINAL    CORD. 

variously  distributed,  and  for  the  anterior  part  of  the  body  the  action  of 
the  latter  is  crossed,  this  action  being  more  perfect  in  the  fibers  of  the 
middle  third  of  the  lateral  columns.  There  are  also  motor  fibers  in  this 
part  of  the  cord.  His  experiments  show  that  irritation  of  the  peripheral 
sensory  nerves  of  the  limb  of  an  animal  in  front  of  the  lesion  of  the  cord, 
produces  only  reflex  movements  in  the  limb  on  one  side,  which  is  wholly 
or  in  part  uninjured.  If,  however,  this  part  of  the  lateral  column 
is  destroyed,  it  is  impossible  to  cause  reflex  movements  in  the  hind 
limb,  even  when  excitation  of  the  anterior  part  of  the  body  is  severe. 
It  was  found  that  if  the  anterior  half  of  the  lateral  columns  was  not 
intact,  no  reflex  movements  could  possibly  be  induced.  Electrical  exci- 
tation of  the  cervical  cord  "  caused  repeated  alternate  flexion  or  exten- 
sion, or  tetanic  contraction  of  the  limbs."  The  first  would  not  follow  if 
the  middle  third  of  the  lateral  columns  Avas  not  intact.  The  clonic  con- 
tractions took  place  even  when  the  corresponding  lateral  column  was  de- 
stroyed. In  regard  to  the  production  of  the  tendon-reflex,  Schultz  ^  and  Fu- 
erbringer  have  experimented  by  dividing  the  cords  of  rabbits  and  exposing 
the  tendons.  They  have  come  to  the  conclusion  that  the  phenomena  of 
tendon  reflex  are  not  those  which  result  from  a  local  excitation  through 
muscles,  nor  that  such  movements  ai'e  skin  reflexes,  but  that  there  is  local 
irritation  of  certain  nerves  described  by  Sachs,"  which  have  terminal, fila- 
ments in  the  tendons.  We  are  also  reminded  by  Erb,^  that  the  tendon 
reflex  occurs  even  when  the  tendon  is  tapped  in  situations  where  there 
is  underlying  bone,  and  Avhere  there  is  no  possibility  of  jar  or  mechanical 
irritation  of  the  attached  muscles.  The  tendon  in  a  relaxed  condition 
can  even  be  pinched  when  held  in  the  fingers,  and  contraction  will 
follow. 

To  do  away  with  the  possibility  of  cutaneous  irritation,  the  skin  may 
be  anaesthetized  by  the  local  spray,  and  the  same  thing  then  occurs. 

In  some  of  Erb's  cases,  the  tendon-reflex  could  be  excited  by  pressure 
over  one  of  the  lumbar  vertebrte,  or  over  other  bony  prominences  ;  but 
in  this  case  there  was  no  secondary  reflex.  In  examples  where  irritation 
of  the  skin  gives  rise  to  the  tendinous  movement,  the  same  are  likewise 
secondary. 

It  has  also  been  found  that  pressure  on  the  central  nerve  will  diminish, 
if  not  stop,  the  various  expressions  of  heightened  reflex  in  the  lower  ex- 
tremities. The  difierent  phenomena  of  the  tendinous  reflex  depend  upon 
the  integrity  not  only  of  sensory  nerves,  but  the  paths  of  sensory  con- 
dition in  the  posterior  columns;  and  Henz*  observes  that  in  certain 
hemiplegise  connected  with  hemi-antesthesia,  the  probable  failure  in  pro- 
ducing tendinous  and  other  reflexes  depends  not  so  much  upon  the  paresis 
of  the  muscle,  as  upon  the  insensibility  of  the  integument,  or  the  nerves  of 

1  Centralblatt  f.  d.  Med.  Wiss.,  No.  54,  1875. 

^  Eeichert  and  Du  Bois  Keyraond's  Archiv.  iv.,  1875,  p.  402. 

^  Ziemssen's  Cyclop.,  vol.  xiii.,  p.  49. 

*  St.  Petersburg  Med.  Wochenschrift,  No.  35,  Oct.  30,  1876. 


DISEASES   OP   THE   LATERAL   COLUMNS   OP   THE   SPINAL   CORD.      363 

the  sinews.  The  central  conditions  which  enter  into  the  production  of 
exaggerated  states  of  the  tendinous  reflex,  and  of  the  reflex  disorders 
of  motility,  are — • 

1st.  A  condition  of  irritation  or  inflammation  of  the  central  gray  sub- 
stance; 

2nd.  A  suspension  of  inhibition.^ 

In  this  case  the  lesions  involve  the  strands  of  nervous  conducting  mat- 
ter concerned  in  the  transmission  of  cerebral  or  local  inhibition. 

In  the  diseases  under  discussion,  it  would  appear  that  the  last  of  these 
is  that  which  enters  into  the  pathology  of  diseases  of  the  lateral  columns  ; 
for  in  the  majority  of  cases  the  gray  matter  is  intact. 

The  careful  investigations  of  Flechsig,  already  referred  to,  demon- 
strate that  certain  fibers  in  the  lateral  columns  are  connected  with  certain 
cells  in  the  anterior  cornua  and  other  parts ;  and  that  in  disease  affecting 
this  part  of  the  cord,  the  spinal  inhibitory  action  which  is  acknowledged 
by  nearly  all  neuro-physiologists,  among  them  Erb,^  Brunton,^  and  others, 
to  enter  into  the  production  of  certain  motor  impulses  of  spinal  origin,  is 
suspended. 

Allusion  has  been  made,  in  speaking  of  symptomatology,  to  the  fact 
that  an  original  excitation  of  a  tendon  was  often  followed  by  a  series  of 
muscular  contractions. 

This  has  been  noticed  by  Freusberg;  and  according  to  Pfleuger*  it  is 
explained  by  the  theory  that  the  original  excitation  is  transformed  from 
sensory  to  a  motor  fiber  on  the  same  side  of  the  cord ;  and  then  by 
others  on  the  other  side ;  thence  back,  following  a  zigzag  course  and 
giving  rise  to  unequal  muscular  motorial  innervation,  and  this  will  also 
explain  the  occurrence  of  transmitted  reflexes  to  the  other  side  of 
the  body. 

The  contractions  which  occur  are  due  to  a  tonic  rigidity  of  the 
flexors  and  are  rarely  if  ever  attended  by  any  change  of  substance  or 
tissue  of  the  muscle,  but  are  due  to  an  irritation  of  central  nervous 
tracts. 

The  spastic  gait  is  the  result  of  reflex  contraction  of  the  muscles,  de- 
pendent upon  retractions  of  the  tendons ;  and  with  this  a  certain 
paresis.  The  early  sensory  disturbances  are  due  probably  to  irritation  of 
the  posterior  nerve-roots,  or  perhaps  to  parts  of  the  lateral  columns  which 
have  been  found  by  Ludwig  and  others  to  be  concerned  in  the  transmis- 
sion of  sensory  impressions ;  and,  as  a  consequence,  the  dragging  neural- 
gic pains  and  burning. 

^  In  regard  to  the  suspension  of  cerebral  inhibition,  I  think  we  may  make  use  o^ 
the  hysterical  cases  of  lateral  column  degeneration  to  explain  how  an  inveterate 
voluntary  paralysis,  such  as  occurs  in  hysteria,  may  by  a  continuous  arrest  of  inhibi- 
tion of  the  central  variety,  lead  to  a  degeneration  of  parts  concerned  in  the  trans- 
mission of  voluntary  impressions. 

2  Op.  cit. 

^  West  Kiding  Reports,  vol.  iv. 

*  Quoted  by  Erb. 


364  DISEASES    OF    THE    SPINAL    CORD. 

The  gross  appearances  of  disease  of  the  lateral  columns  present  many 
variations ;  and  markedly  differ  in  regard  to  situation  and  degree  of  de- 
genei'ation.  It  is  unusual  to  find  absolute  non-involvement  of  the  other 
columns  of  the  coi-d,  as  in  the  case  observed  by  Westphal,  and  alluded 
to  by  Erb.  The  posterior  columns  are  liable  to  be  affected  to  some  ex- 
tent ;  and  this  complication  affects  very  slightly  the  clinical  features  of 
this  disease ;  while  if  there  be  involvement  of  the  anterior  columns, 
the  conspicuous  atrophy  will  give  to  the  disease  picture  a  very 
different  aspect.  This  condition  of  affairs  was  witnessed  in  a  case  of 
anomalous  progressive  atrophy  brought  forward  recently  by  Shaw/ 
and  there  are  additional  cases  of  this  character  reported  by  French 
authors. 

So  far,  no  autopsies  have  been  made  which  revealed  uncomplicated 
disease. 

In  a  case  which  has  been  diagnosed  by  Charcot^  to  be  one  of  pure 
"  Tabes  dorsalis  spasmodique,"  the  disease  of  the  cord  came  more  prop- 
erly under  the  head  of  disseminated  sclerosis  than  local  degeneration. 
This  case  is  mentioned  in  Betou's  thesis.  Ollivier  gives  autopsical  re- 
sults, but  these  are  too  indefinitely  detailed,  and  too  inexact  to  be  of 
much  service.  The  cases,  however,  which  are  of  greatest  interest  to  us, 
are  those  in  which  there  has  been  secondary  disease.  It  has  been 
assumed  by  Charcot,  and  in  some  of  his  hysterical  cases  it  has  been 
found,  that  the  form  of  degeneration  known  as  "  primary "  occupies  a 
wedge-shaped  area  beginning  at  the  cord,  and  extending  through  both 
the  cerebellar  and  crossed  pyramidal  columns. 

In  one  of  his  cases  ^  the  sclerosis  was  found  to  involve  the  entire  length 
of  both  lateral  columns,  while  other  parts  were  perfectly  healthy.  There 
was  no  trace  of  meningitis,  and  the  character  of  the  semi-gelatinous, 
grayish  change,  was  unmistakably  sclerosis.  The  microscope  revealed 
atrophy  and  disappearance  of  nerve  tubes  with  annular  constrictions. 
The  gray  matter  was  intact  and  the  cells  unaffected.  There  was  in- 
crease of  connective  tissue  and  an  abundant  deposit  of  amyloid  cells. 
In  the  descending  secondary  degeneration  consecutive  to  cerebral  dis- 
ease, the  lesion  will  be  found  on  one  side  only,  and  the  crossed  pyramidal 
fibres  will  be  affected  ;  while  if  this  descending  form  be  seen  as  the 
result  of  spinal  disease,  the  lesion  will  be  bi-lateral  and  may  involve  other 
parts  as  well  in  the  lateral  columns  at  a  different  place. 

An  ascending  lesion,  according  to  Erb,*  Pitres,^  and  others,  is  usually 
characterized  by  degeneration  of  a  narrow  peripheral  border  of  tissue 
confined  to  the  cortex  and  extending  forwards  somewhat  as  far  as  the  an- 
terior nerve-root  tracts. 


^  Journal  of  Mental  and  Nervous  Diseases,  January,  1879. 

^  Lefon&j  etc.,  1878,  p.  294. 

3  Gaz.  Hebdom.,  No.  7,  186-5,  p.  109. 

♦  Op.  cit.  vol.  xiii.,  p.  773. 

5Gaz.  Med.  de  Paris,  1877. 


DISEASES   OF   THE   LATERAL   COLUMNS   OF   THE   SPI^'AL   COED.      365 

I  have  already  sufficiently  alluded  to  anomalies  in  development  of  the 
cord  and  the  destruction  of  certain  parts  by  disease  before  birth.  Under 
this  class  comes  the  case  detailed  by  Schultze/  in  which,  with  hydrocepha- 
lus, there  was  congenital  non-develoj)ment  of  the  spinal  motor  tracts  and 
myelitis.  Should  the  degeneration  follow  Pott's  disease,  Leyden  ■  is  of  the 
opinion  that  it  begins  at  the  point  of  compression  and  extends  down- 
wards, although  Michaud  has  found  in  some  cases  of  slow  compression 
that  myelitis  ascends  in  these  columns.  Should  the  cortex  be  involved 
primarily,  and  be  the  seat  of  a  myelitis,  it  will  be  found  that  there  is 
thickening  of  the  neuroglia,  from  the  periphery  to  the  centre,  just  as  in 
the  primary  sclerosis. 

According  to  Lange,  softening  is  a  common  form  of  degeneration,  and 
the  fibres  of  connective  tissue  are  not  uniformly  thickened,  but  such  in- 
crease of  volume  is  detected  here  and  there  in  the  midst  of  the  diseased 
mass,  and  irregularly-shaped  nuclei  will  be  found  attached  to  their  sides. 
In  a  case  of  my  own,  that  of  a  girl  who  had  died  after  suffering  for  some 
years  from  chronic  myelitis  (her  limbs  being  contracted,  especially  the 
upper),  it  was  found  that  the  cord,  especially  in  the  cervical  region,  pre- 
sented evidences  of  lateral  sclerosis,  which  were  more  marked  on  the 
right  side.  A  transverse  section  of  the  cord  at  the  cervical  region,  under 
a  low  power,  presented  the  appearances  depicted  in  Fig.  57.^ 

Microscopic  examination  revealed  on  both  sides  a  hyperplasia  of  con- 
nective tissue,  which  was  most  dense  at  the  periphery  of  the  cord,  while 
there  was  a  compact  network  of  fibres  which  interlaced  and  extended  to 
the  centre.  While  the  thickening  was  perceptible  in  the  anterior  root- 
zone,  it  was  especially  marked  in  the  posterior  part  of  the  lateral  columns. 
With  a  low  power,  a  dark  triangular  segment  of  dense  connective  tissue 
was  observed  extending  from  the  perijDhery  to  the  outer  border  of  the  cen- 
tral gray  matter.  Extending  posteriorly  to  a  point  limited  by  an  imagi- 
nary line  drawn  from  the  posterior  group  of  ganglion  cells  in  the  tractus 
intermedio  lateralis  to  the  border  of  the  cord  internally  (i.  e.  adjacent 
to  the  gray  matter  of  the  posterior  horns),  was  found  a  reticulated  ar- 
rangement of  thickened  fibres,  the  interspaces  becoming  smaller,  and  the 
neuroglia  more  dense,  until  within  a  short  distance  of  the  direct  fibres  of 
the  cerebellar  column.  At  this  part  the  spaces  become  larger  and  elon- 
gated, and  the  fibers  more  prominent.  In  the  anterior  part  of  this  dense 
tissue  were  found  arterioles  with  thickened  walls  surrounded  by  granular 
substance  which  had  been  thrown  out.  In  the  spaces  between  the  thick- 
ened connective  tissue,  there  was  a  general  disappearance  of  nerve  tubes, 
which  was  most  conspicuous  towards  the  periphery,  where  in  certain  local- 
ities but  two  or  three  fibers  could  be  detected.  The  axis  cylinders  in  some 
places  were  swollen,  and  there  was  a  scattered  deposit  of  granular  sub- 
stances, which  was  the  result  of  "  breaking  down  "  of  the  connective  tissue 

1  Centralblatt,  No.  10,  1876. 

^  Klinik  der  Eiickenmarks  krankeheiten,  Erste  Band.  '     • 

2  Abst.  in  Schmidt's  Jahrsbericht,  168,  1875,  p.  238. 


366 


DISEASES    OF    THE    SPINAL    CORD, 


cells.  The  ganglion  cells  of  both  anterior  horns  were  seemingly  unaffected 
and  their  nuclei  were  distinct.  The  columns  of  Goll  were  also  found  to 
be  the  seat  of  sclerosis. 

It  is  possible  that  in  this  affection  there  may  be  several  grades  of  patho- 
logical trouble. 

Fis.  57. 


I     V 

a.  a.  b.  b.  Sclerosed  Tracts. 


In  Lange's^  communication  attention  is  directed  to  two  conditions  de- 
pendent upon  varying  degrees  of  diseased  action  : — 1.  Simple  gray"  colora- 
tion without  any  destruction  of  nerve  tubes.  With  this  there  is  a  promi- 
nence of  neuroglia  cells,  while  there  is  an  increased  clearness  of  the  nuclei. 
The  general  discoloration  is  darker  than  in  the  next  form.  2.  Sclerosis,  in 
which  the  main  element  is  increase  of  connective  tissue,  and  destruction 
of  nerve  tubes. 

It  is  probable  that  these  two  conditions  are  those  which  are  to  be  found 
in  cases  of  slow  progress,  while  a  myelitis  with  softening  is  probably  not 
uncommon  in  the  secondary  forms. 

The  changes  which  begin  in  simple  discoloration  and  extend  to  sclero- 
sis, include  a  list  of  slow  changes  of  a  progressive  character.  The  nerve 
tubes  appear  at  first  altered  in  calibre  and  become  swollen ;  their  axis 
cylinders  also  swell,  and  there  is  unequal  bulging  of  the  membranes,  giv- 
ing rise  to  an  appearance  of  varicosity.     Granular  degeneration  is  proba- 


'  Op.  cit. 


DISEASES   OF   THE   LATERAL   COLUMNS   OP   THE   SPINAL    CORD.      367 

bly  the  next  step  in  the  process ;  and  ultimately  there  is  shrinking  of  the 
nerve  fibers  and  disappearance.  In  secondary  cases  the  existence  of 
myelitis  in  other  parts  is  to  be  observed  ;  but  the  main  appearance  of 
the  morbid  process  is  to  be  localized.  In  many  of  these  examples  it  is 
probable  that  the  disease  began  by  a  simple  ischsemic  state,  in  some  such 
pathological  condition  as  the  gray  discoloration  of  Lange. 

Diagnosis. — The  diagnosis  of  disease  of  the  lateral  columns  of  the 
spinal  cord  is  usually  unattended  by  many  difficulties  ;  and  the  group  of 
symptoms  is  too  conspicuous  and  well-marked  to  permit  the  ob- 
server to  err.  Loss  of  power  without  atrophy,  and  reflex  excita- 
bility without  diminished  sensibility  enter  into  the  formation  of 
a  unique  train  of  symptoms;  and  unlike  those  of  many  spinal  dis- 
eases, they  are  never  separated  in  fully  developed  disease  of  this  part 
of  the  cord.  In  speaking  of  the  infantile  form,  I  have  alluded  to 
several  paralytic  disorders  of  infancy  with  which  it  might  be  con- 
founded. I  have  been  fortunate  enough  to  see  a  case  of  double  talipes, 
the  result  of  infantile  paralysis,  which  at  first  suggested  the  disease  in 
question ;  but  even  in  this  case  the  loss  of  electric  muscular  contractility 
(though  there  was  not  the  extensive  atrophy  which  might  have  been  ex- 
pected), led  me  to  make  a  diagnosis  of  that  much  more  common  form  of 
infantile  disorder — infantile  paralysis. 

As  to  the  primary  disease  of  adult  life,  not  much  is  to  be  said.  It 
might  possibly  be  mistaken  for  transverse  myelitis,  in  which  the  urinary 
and  vesical  functions  are  involved,  with  bed-sores  and  anaesthesia. 
Locomotor  ataxia  cannot  be  mistaken  for  the  disease  ;  for  in  certainly  half 
if  not  more  of  the  cases  the  patellar  tendon-reflex  is  absent.  There  are, 
in  addition,  the  symptoms  of  ataxia,  loss  of  muscular  sense,  anaesthesia  of 
the  tactile  variety,  optic  nerve  disease,  and  visceral  pains. 

The  gait  in  the  two  diseases  is  radically  difierent.  In  locomotor  ataxia, 
the  patient  throws  out  his  feet,  coming  down  on  his  heels  ;  while  in  all 
forms  of  degeneration  of  the  lateral  columns,  as  has  been  shown,  there  is 
a  tendency  to  walk  on  the  toes — the  feet  seem  to  cling  to  the  ground  ; 
and  there  is  adduction  of  the  thighs. 

In  disseminated  sclerosis,  there  is  usually  tremor,  irregular  involve- 
ment of  the  extremities,  cephalic  disorders,  and  generally  more  or  less 
ataxia. 

Chronic  myelitis  of  the  anterior  columns,  progressive  muscular  atrophy, 
and  amyotrophic  lateral  sclerosis,  may  all  resemble,  in  certain  features,  the 
disease  under  consideration — although  if  atrophy  is  conspicuous,  the  di- 
agnosis is  easy  enough  ;  but  occasionally,  an  anomalous  case  is  sufficiently 
puzzling  to  create  a  doubt. 

I  have  seen  a  case  of  progressive  muscular  atrophy  of  the  lower  ex- 
tremities which  presented  exaggerated  reflex  excitement  of  the  tendons. 
There  was  a  general  trepidation  which  could  not  possibly  be  mistaken  for 
the  unequal  muscular  contractions  known  as  vermicular  tremor ;  but  in 
this  case  there  was  a  difference  of  an  inch  and  a  half  in  the  circumfer- 
ence of  the  thigh,  and  the  muscles  of  the  neck  were  unevenly  atrophied ; 


368  DISEASES    OF    THE    SPINAL    CORD. 

while  added  to  the  features  of  progressive  muscular  atrophy  there  was  a 
commencing  aphonia  and  other  bulbar  symptoms. 

In  adult  chronic  spinal  paralysis  the  development  of  the  disease  may  be 
so  insidious  as  to  give  rise  to  a  reasonable  suspicion  as  to  its  true  nature ; 
and  should  there  be  added  thereto  slow  contractions  of  the  dorsal  muscles, 
the  diagiiosis  will  be  still  more  puzzling.  In  such  cases  the  tendon-reflex 
will  be  found  to  be  lowered  or  absent,  and  the  contractures  which  result 
are  not  those  of  the  spastic  variety,  but  rather  of  paralyzed  muscles  op- 
posed to  those  which  are  not. 

The  forms  of  secondary  origin  are  more  difiicult  to  recognize  ;  for  com- 
plicating symptoms  play  a  part  which  greatly  confuses  the  observer. 
There  may  be  all  the  symptoms  of  unequal  congestion,  of  myelitis,  or  of 
concussion  of  parts  other  than  the  lateral  columns  ;  and  time  is  required 
before  it  is  possible  to  arrive  at  a  conclusion. 

In  such  cases,  the  involvement  of  parts  above  the  lesion  is  significant. 
A  paraplegia  of  the  lower  extremities  may  exist  and  be  connected  with 
anaesthesia,  retention  and  incontinence,  and  even  bed-sores  ;  but  at  a  later 
period,  the  arms  may  become  the  seat  of  paresis  without  anaesthesia,  but 
with  highly-developed  tendon-reflex ;  and  at  this  stage  it  is  possible  to 
find  diminution  of  the  symptoms  of  an  inferior  transverse  myelitis,  the 
ansesthesia  clearing  away,  the  function  of  the  bowels  and  bladder  being 
restored,  and  the  gait  becoming  changed ;  while  to  the  paresis  there  is 
added  an  excitement  of  the  tendon-reflex  ;  but  of  course  such  cases  are 
rare.  Should  there  be  anaesthesia,  however,  the  case  may  be  supposed  to 
be  one  of  central  or  posterior  myelitis.  The  diagnosis  of  hysteria  is  some- 
times attended  with  difficulty ;  but  it  may  be  borne  in  mind  that  the 
paralysis  is  one  of  a  purely  voluntary  kind  in  the  beginning. 

In  this  connection  the  reader  is  referred  to  an  admirable  article  by 
Ferber  and  Gasser^  upon  certain  forms  of  contractures  of  the  hands  and 
fingers  who  report  the  case  of  E.  Gull,  a  woman  39  years  old,  who  had 
suffered  for  some  time  from  irregular  menstruation  ;  and  for  several  years 
there  had  been  periodic  contractions  of  the  hand  and  fingers.  After- 
wards the  hands  became  permanently  contracted,  there  being  spasms 
of  the  flexors  without  any  atrophy  whatever.  The  muscles  con- 
tracted were  the  common  flexors  of  the  hands,  as  well  as  the  adductors 
of  the  thumbs  and  interossei.  Dr.  Buzzard  in  a  recent  communication 
to  the  Lancet  ^  speaks  of  the  difficulty  of  diagnosing  the  cases  of  hys- 
terical origin  from  those  of  a  purely  organic  character. 

Prognosis. — Infantile  cases  may  be  said  to  be  utterly  hopeless  except 
when  secondary  to  Pott's  disease  ;  and  neither  medical  or  surgical  treat- 
ment have  so  far  proved  of  the  least  permanent  benefit. 

With  cases  of  primary  degeneration,  or  of  the  functional  form,  the 
matter  is  diSerent.  Erb  has  spoken  of  improvement ;  and  the  cases 
brought  forward  by  Kussmaul,  Berger  and  others,  show  that  the  progno- 

^  Archiv.  fiir  Psychiatrie,  etc.,  vij.,  p.  140,  1877. 
^London  Lancet,  June,  1881. 


DISEASES   OF   THE   LATERAL   COLUMNS   OF   THE   SPINAL   CORD.     369 

sis  is  not  utterly  .bad,  and  Nixon's  case  of  antero-lateral  sclerosis  was 
greatly  benefited  by  tbe  remedies  of  which  I  have  spoken. 

Hysterical  cases  are  always  rebellious,  as  the  central  disease  is  the  con- 
sequence of  a  long  existing  nervous  condition  ;  and  not  only  is  the  psychi- 
cal influence  difficult  to  combat,  but  the  degeneration  itself  is  of  so  ex- 
tensive a  character  that  it  defies  successful  treatment.  Strange  to  say, 
secondary  affections  of  spinal  origin  are  not  utterly  beyond  the  reach  of 
treatment.  This  is  especially  true  in  secondary  degeneration  or  local 
disturbance  after  concussion.  Erichsen^  in  his  well-known  work  alludes 
to  certain  cases  in  which  there  was  quite  extensive  spinal  trouble  from 
railroad  injury  with  symptoms  indicative  of  lateral  column  disease,  and 
yet  recovery  took  place.  Should  such  concussion  be  unattended  by 
laceration  of  nervous  substance,  there  is  some  chance  for  improvement. 

Should  there  be  extension  upwards,  as  occurs  sometimes  in  both  the 
primary  and  secondary  form  of  disease,  there  may  be  bulbar  symptoms 
and  death ;  while  if  the  cervical  region  of  the  cord  be  the  district  ulti- 
mately attacked,  serious  pulmonary  symptoms  may  be  added  to  those  of 
the  disease. 

Treatment :  In  the  favorable  case  treated  by  Kussmaul,the  chloride 
of  gold  and  sodium  in  doses  of  gr.  ^  t.  i.  d.,  was  used  until  the  patient  had 
taken  ninety  grains  in  all.  Erb  places  nitrate  of  silver  at  the  head  of 
the  list  of  drugs,  and  at  the  same  time  recommends  hydropathy. 

It  would  seem  that  Nixon  ^  also  has  found  benefit  to  follow  the  use  of 
the  silver  salt ;  and  much  improvement  followed  in  his  case  under  the 
continued  administration  of  the  following  prescription  : 

R 

Argenti  Nltratis, 

Ext.  Nucis  Vomicae,  aa  gr.  jv. 

Ext.  Gentianse,  q.     s. 

TTL    Divid  in  pill  Xo.  xii. 
Sig.  One  ter  in  die. 

Charcot  is  also  in  favor  of  the  nitrate  of  silver,  and  suggests  in  addi- 
tion the  application  of  the  cautery  along  the  spine.  He  has  used  the 
bromide  of  ammonium  and  sodium  in  large  doses  to  diminish  trepidation 
and  spasms,  and  has  met  with  excellent  results. 

Faradism  by  means  of  the  wire  brush  is  recommended,  and  galvanism 
(the  continuous  current)  has  been  of  service  in  Erb's  hands.  Strychnine 
is  advised  against  when  there  is  so  much  reflex  disturbance.  Thermal 
saline  spring  baths  have  been  praised  ;  but  it  has  been  found  that  inter- 
nally the  waters  do  no  good. 

In  my  own  practice,  I  have  found  that  the  Fl.  Ext.  of  Conium  in 
doses  of  five  minims  thrice  daily  to  be  increased,  is  the  best  remedy  to 
diminish  the  violence  of  the  trepidation,  while  belladonna  or  the  sulph. 


^  Concussion  of  the  spine  and  nervous  shock,  etc 
2  Dublin  Monthly  Journal,  vol.  Iviii.,  1874,  p.  207, 
24 


370  DISEASES    OF    THE    SPINAL    CORD. 

of  atropia  in  local  hypodermic  injections  of  grs.  ^V,  is  useful  when  there 
is  great  spastic  rigidity.  Hyoscyaniia  acts  well  and  is  an  admii-able  anti- 
spasmodic. 

As  to  other  internal  remedies,  I  have  given  phosphorus,  the  nitrate  of 
silver,  and  chloride  of  gold  a  fair  trial,  but  am  disposed  to  place  more 
reliance  on  cod-liver  oil,  ergot,  or  some  salt  of  mercury  for  the  treatment 
of  the  central  disease,  fully  believing  that  nutrition  should  be  improved 
and  the  local  circulation  modified. 

I  have  found  that  the  utmost  quiet  is  necessary  not  only  for  the  com- 
fort of  the  patient,  but  for  the  amelioration  of  the  disease.  He  should 
be  kept  still,  and  not  allowed  to  take  fatiguing  exercise ;  and  all  sources 
of  reflex  excitation  should  be  avoided.  For  the  hysterical  cases,  we 
should  pursue  a  different  course  and  endeavor  to  make  them  bring  into 
use  the  muscles  of  the  affected  limb.  For  cases  of  secondary  origin,  the 
galvanic  current  seems  to  possess  great  advantages;  and  should  there 
be  meningeal  troubles,  the  administration  of  ergot  is  to  be  pushed.  If  the 
case  be  like  one  reported  by  Leyden,  and  probably  rightly  supposed 
by  Erb  to  be  of  specific  origin,  it  is  necessary  to  give  the  iodide  of 
potassium. 

TETANUS. 

Synonyms. — Rigor  nervosus;  Mai  de  cerf;  Tetanos  (Fr.)  ;  Locked 
jaw. 

Definition. — Tetanus  is  an  affection  characterized  by  tonic  spasms  of 
a  great  number  of  muscles,  particularly  those  of  the  jaw,  neck,  back,  and 
lower  extremities.  It  is  never  attended  by  loss  of  consciousness,  and 
nearly  always  approaches  an  unfavorable  termination.  It  is  a  disease 
which  may  be  either  idiopathic  or  traumatic,  and  is  not  confined  to  any 
age  or  sex,  as  it  may  be  a  condition  at  birth  (trismus  nascentium),  or  occur 
at  any  subsequent  time. 

Symptoms. — The  more  familiar  examples  follow  wounds,  and  such 
injuries  may  be  exceedingly  slight — the  puncture  of  a  rusty  nail,  a 
needle  or  a  blunt  instrument  being  often  likely  to  give  rise  to  the  attack  ; 
or  it  may  be  of  distinctly  idiopathic  origin.  The  first  symptoms  generally 
noticed  are  a  stiffness  of  the  neck,  a  slight  soreness  of  the  throat,  and  a 
contraction  of  the  jaws  so  that  it  may  be  difficult  for  the  patient  to  open 
his  mouth.  There  may  be  general  malaise  and  discomfort,  which  may 
last  for  several  days,  and  the  patient  is  unable  to  masticate  or  swallow  his 
food  properly,  and  consequently  eats  but  little.  He  may  think  that  he 
Las  simply  caught  cold,  and  neglect  to  seek  medical  advice  ;  but  new 
developments  will  show  the  condition  to  be  more  serious  than  he  ima- 
gines. 

The  closure  of  the  jaw  may  become  more  complete,  and  within  the  next 
twenty-four  hours  (the  fourth  or  fifth  day  of  the  affection)  he  will  show 
unmistakable  signs  of  the  increasing  violence  of  the  disease.  His  face 
wears  the  peculiar  expression  which  has  been  called  the  ristis  sardonicus, 
the  features  appearing  jiinched  and  set,  and  the  corners  of  the  mouth  are 


iBT  xycs.  371 

drawn  upwards,  while  the  eyes  are  prominent  and  the  hair  and  eyebrows 
quite  bristling.    The  brows  are  knit,  and  there  is  a  characteristic  appear- 
ance, which,  if  once  seen,  cannot  be  mistaken.     Eadcliffe  considers  the 
risus  sardonicus  quite  pathognomonic  of  tetanus.     Pain  in  the  epigas- 
trium becomes  very  severe,  and  is  not  relieved  by  medicine.     It  is  impos- 
sible sometimes  to  open  the  jaws  even  when  we  desire  to  give  food  or 
medicine,  and  it  is  sometimes  necessary  to  use  quills  and  other  delicate 
tubes  for  the  purpose  of  feeding.     Spasms  of  the  pharyngeal  muscles  may 
also  defeat  all  attempts  of  this  kind,  for,  even  if  the  teeth  are  parted  and 
nourishment  is  inserted,  the  food  is  forced  with  great  violence  through 
the  nostrils      Other  sj)asms  now  mark  the  progress  of  the  disease.     The 
muscles  of  the  back  begin  to  be  convulsed,  and  finally  those  of  the  lower 
extremities,  and  as  a  consequence  we  observe  the  appearance  of  opidlwto- 
nos,  which  is  an  extremely  striking  symptom,  and  much  more  common 
than  eniprodhotonos,  which  may  also  take  place,  or  pleurodhotonos.     It  is 
hardly  necessary  to  say  that  opisthotonos  is  the  result  f.f  a  tonic  spa^m  of 
the  muscles  of  the  back,  so  that  the  patient's  body  describes  an  arc,  the 
head  and  heels  touching  the  surface  upon  which  he  is  lying,  and  the  mid- 
dle of  the  back  being  raised  some  distance  therefrom.    When  the  body  is 
bent  in  the  opposite  direction — forward — the  condition  is  known  as  em- 
prosthotonos ;  and. when  the  muscles   upon  one  side  of  the  body  are  con- 
tracted we  designate  the  lateral  curve  produced  as  pleurosthotonos.     Dur- 
ing this  tonic  convulsive  state   individual  muscles  may  be  the  seat  of 
painful  spasms,   which  are  very  agonizing.       Muscles  have  been  torn 
across  and  bones  broken  by  the  great  strain,  and  the  force  exerted  is 
something  wonderful.     The  tongue  is  rarely  affected,  and  the  hands  are 
not  usually  at  any  time  rigid  or  contracted.     The  sj^asms  are  easily  pro- 
duced by  slight  agencies,  as  reflex  irritability  is  decidedly  exaggerated. 
Jarring  the  bed,  tickling  of  the  soles,  or  a  draught  of  air  allowed  to  blow 
upon  the  surface  will  immediately  bring  them  on.     This  convulsive  stage 
lasts  until  death,  but  when  the  end  is  approaching  becomes  less  sthenic 
as  the  patient  grows  more  and  more  exhausted.     There  may  be  an  occa- 
sional severe  paroxysm  before  death,    but  it  is  not  at  all  like  the  form  of 
violent  convulsion  of  the  middle  stages.     The  pulse  throughout  the  de- 
veloped disease  is  very  rapid  and  fluttering  and  ranges  between  120  and 
140,  and  the  respiratory  movements  are  irregular  and  catching,  as  the 
spasms  aflect  the  muscles  of  the  thorax  as  well  as  others  which  are  directly 
concerned  in  this  process.     Dyspncea  is  very  distressing,  and  is  expressed 
between  the  seizures  by  much  gasping  and  anxiety  of  countenance.     The 
skin  is  dark,  and  large  rings  about  the  eyes  are  indicative  of  collapse, 
while  the  face  of  the  victim  is  haggard  and  depressed.     The  patient 
perspires  quite  profusely,  and  the  skin  is  excessively  hot ;  and  a  pro- 
minent feature  of  tetanus  is  the  marked  elevation  of  temperature,  which 
rises  even  sometimes  as  high  as  110^,  and  actually  reaches  a  higher 
point  after  death.     In  a  case  observed  by  AVunderlich^  there  was  a  mar- 
vellous elevation  of  this  kind,  and  a  very  tardy  fall  after  death. 

1  Archiv.  der  Heilkunde,  Bd.  ii.,  and  v.  (1861-63).   Reported  by  Radcliffe. 


372 


DISEASES    OF    THE    SPINAL    CORD. 


Date. 

Respiration. 

T,  ,  „                 Temperature 
Pulse.                 (Fahrenheit). 

24tli  July,  1S61    .... 

24 

96 

102° 

25th 

'         "        . 

22 

82 

102 

26th 

"    9  A.  M.  . 

20 

96 

104.45 

<( 

"     6  R  M.  . 

32 

112 

103.55 

<i 

"    9.20  P.  M 
"         "     9.35  P.  M.,  death, 

36 

180 

110.1 
112.55 

after  death,   2' 

112.77 

"       5' 

113 

"        "    20' 

113.22 

"     35' 

113.55 

"     55' 

113.67 

"     60' 

113.55 

"    70' 

113.22 

"     90' 

113 

"        "  100' 

111.8 

"        «       6  hours 

106.25 

"        "      9      " 

104 

«        (<     12      " 

102 

"     13J    " 

• 

101 

Dr.  Joseph  Jones,  of  New  Orleans,  the  author  of  one  of  the  most  able 
articles  upon  this  subject  that  has  ever  appeared,  has  made  numerous  ex- 
aminations of  the  urine.  He  found  that  the  quantity  of  urine  excreted 
during  the  "  active  stages  was  greatly  diminished  from  the  normal  stand- 
ard, and  in  the  successful  cases  treated  the  amount  increased  with  subsi- 
dence of  the  symptoms."  He  also  found  that  the  urea  was  increased 
during  the  active  stages,  and  the  uric  acid  was  diminished. 

The  diminution  of  the  excretion  of  urine  is  by  him  supposed  to  be  ac- 
counted for  by  the  small  quantity  of  fluids  taken,  and  by  the  loss  of  liquid 
in  profuse  persjiiration. 

The  mind  is  perfectly  clear  throughout  the  disease,  and  the  patient  suf- 
fers great  mental  misery  as  he  fully  realizes  his  terrible  condition  ;  and 
sleep  is  nearly  always  absent,  this  being  one  of  the  most  distressing  fea- 
tures of  the  disease.  If  this  is  obtained,  even  in  brief  snatches,  the  mus- 
cles are  relaxed,  and  all  spasms  disappear  for  the  time,  but  immediately 
reappear  upon  awaking.  The  probable  cause  of  death  is  either  the 
closure  of  the  glottis,  or  exhaustion,  which  is  an  inevitable  result  of  the 
violent  muscular  action.  In  new-born  children  the  disease  sometimes 
appears  between  the  first  and  fifth  days,  the  first  symptoms  noted  being 
restlessness,  trembling  of  the  lower  jaw,  and  desire  for  the  breast,  which 


TETANUS. 


373 


the  child  leaves  almost  immediately.  At  the  end  of  twenty-four  hours, 
or  even  earlier,  the  muscles  of  the  jaw  are  felt  to  be  contracted  and  rigid, 
and  it  cannot  open  its  mouth  ;  there  is  a  peculiarly  aged  expression  upon 
its  face,  the  skin  of  the  forehead  being  wrinkled.  The  eyelids  are  closed, 
and  the  lips  are  comj)ressed  over  the  teeth.  The  head  is  drawn  back, 
and  general  spasms  of  the  muscles  of  the  back  follow.  Periods  of  re- 
mission occur,  and  the  patient  is  thrown  into  a  paroxysm  by  the  most 
trivial  agencies.  The  skin  is  very  red  and  dark,  and  after  a  series 
of  paroxysms,  which  may  continue  for  several  days,  death  closes  the 
scene. 

Causes. — Exposure  to  damp  and  cold  are  the  only  known  exciting 
causes  of  the  idiopathic  variety ;  and  traumatisms  of  certain  kinds,  or 
accidents  during  parturition,  precede  the  other  form.  A  punctured 
wound,  which  may  be  received  from  a  nail  or  splinter,  is  much  more 
likely  to  give  rise  to  tetanus  than  an  incised  wound  ;  and  inj  uries  in 
which  there  is  mangling  or  crushing  of  muscular  tissue  are  frequently 
concerned  in  the  production  of  the  disease.  Railroad  injuries  are  therefore 
especially  dangerous.  Tetanus  sometimes  follows  surgical  operations,  and  it 
has  been  thought  in  these  cases  to  depend  upon  partial  section  of  some 
nerve-trunk.  Dupuytren^  goes  far  enough  to  recommend  re-amputation. 
It  may  be  stated  that  in  certain  regions  there  are  apparent  endemic  influ- 
ences at  the  time  of  such  predisposition,  when  any  surgical  operation  may 
have  this  termination.  This  local  influence  prevails  in  Cuba  and  other 
tropical  countries,  and  in  Long  Island  and  in  other  parts  of  the  American 
seaboard. 

Jones  has  collected  the  statistics  of  tetanus,  and  the  following  table 
shows  its  prevalence  in  hot  climates : — 


Place. 

Period. 

Total    deaths. 

Deaths  from 

tetanus. 

Proportion. 

London 
Ireland 
New  York 
Bombay 

1850-3-4 
1831-1851 
1819-1834 
1851-1853 

224,515 

1,187,374 

83,783 

42,651 

73 

238 
112 
912 

1  in  3075 
1  in  4987 
1  in  748 
1  in  46 

I  am  indebted  to  Dr.  Charles  Findlay,  of  Havana,  Cuba,  for  the  fol- 
lowing concise  table,  which  shows  the  prevalence  of  the  disease  in  that 
island  : — 


^  Lefons  Orales,  tome  ii.  pp.  599-612. 


374 


DISEASES    OF    THE    8PINAL    COED. 


18 

72.'' 

18 

73.  1  1874. 

18 

75. 

18 

76. 

Average.    : 

rr 

w 

CD 

OS 

i 

X 

o6 

iS 

ec 

s 
-o 

< 

4 

47 

■5 

< 

4 

39! 

1 

■5 
< 

3 

C 
1—1 

34 

s 

< 

4 

c 

c 
t— 1 

33 

< 

6 

.2 
c 
I— 1 

17 

B 
< 

42 

C 
1— 1 

January, 

34.0 

Pop.  of  Havana, 
2.50,000. 

February, 

5 

29 

1 

30 

3 

18 

4 

30 

4 

30 

3.4 

27.4 

Births  per  annum, 
5000. 

fi 

94 

3 

?8 

4 

31 

5 

24 

4 

29 

4.4 

27.2 

Deaths  by  tetanu.s  in 

April, 

6 

26 

5 

30 

0 

24 

4 

18 

5 

26 

4.0 

24.8 

Adults=0.192  a  year 
per  1000  inhabil'ts. 

May, 
June, 

3 
2 

27 
24 

1 

3 

29 
33 

3 

2 

33 
36 

I 

30 
29 

3 

5 

35 
39 

30 
3.4 

30.8 
32.2 

Death  of  infantile 
tetanus. 

Julv. 

4 

^o 

5 

20 

4 

31 

3 

36 

3 

35 

3.8 

29.4  7h  perhun'red  births 

August, 

September, 

October, 

3 
3 

35 

2S 

o 

1 

33 
29 

5 
3 

45 
41 

5 
3 

38 
42 

2 
6 

46 
33 

4.0 
32 

37 .41 
34.6 

1 

42 

6 

32 

3 

36 

1 

43 

4 

37 

3.0 

38.0! 

November, 

6 

45 

4 

42 

4 

29 

3 

37 

6 

41 

4.6 

38.8; 

December, 

2 

36 

388 

4 

42 

23 

368 

4 

38 

31 

389 

5 

47 

28 
388 

7 
55 

40 

408 

4.3 

48.4 
4.0 

31.6 

12  months. 

45 

382.5 

5  Yearly  average. 
5  Monthly  average. 

3U 

Loug  Island,  it  seems,  has  gained  an  unenviable  notoriety  as  a  place 
where  "tetanus  is  exceedingly  common ;  but  it  will  be  seen  that  there  is 
much  exaggeration  in  the  reports  which,  as  a  rule,  come  to  us  in  the  news- 
papers, and  which  are  nearly  always  sensational.  I  have  devoted  some 
time  to  the  investigation  of  the  subject,  and  have  written  to  several  well 
known  physicians  of  eastern  Long  Island,  and  have  received  two  or 
three  letters  in  reply. 

Dr.  Stilwell,  an  old  settler  of  Sag  Harbor,  whose  opportunities  for  re- 
search have  been  quite  extensive,  writes  as  follows :  "  About  20  years 
ago  I  came  to  this  place  to  practice,  and  learning  the  fact  of  the  preva- 
lence of  tetanus,  or  its  liability  from  certain  accidents,  I  attempted  an  in- 
vestigation, but  failed  of  any  success  or  satisfaction.  Several  supposed 
cases°having  recovered  naturally  brought  many  cases  under  my  observa- 
tion, but  most  of  them  died.  Several  did  aot,  and  from  my  after-remarks 
here  you  will  perceive  the  reason.  I  have  never  known  the  disease  to 
exist  as  an  epidemic,  but  it  is  apt  at  certain  seasons  of  the  year,  to  follow 
wounds.  Hot  and  damp  weather,  with  cool  evenings,  is  its  favorite  sea- 
son." The  Doctor  has  known  but  two  instances  of  recovery  from  trauma- 
tic tetanus. 

When  a  patient  has  recovered  from  tetanus  it  has  been  by  a  very  slow 
process,  the  period  between  the  spasms  lengthening  until  they  finally  dis- 
appeared. Under  favorable  circumstances  this  required  several  weeks. 
"  I  have  known  fatal   cases  of  idiopathic  tetanus   in   July  and  August 


TETANUS.  375 

caused  by  fatigue  and  overheating,  and  sitting  down  to  cool  off  in  the 
ocean  breezes.  Farmers  have  often  informed  me  that  the  white  frost  on 
grass  would  give  cattle  lockjaw.  I  have  known  a  horse  driven  to  fatigue 
turned  out  to  pasture  in  a  cool  night  when  white  frost  formed  upon  the 
grass,  and  die  with  tetanus.  I  have  known  horses,  in  the  heat  of  summer 
driven  seven  miles  to  the  seashore  and  there  cooled  off  in  the  ocean 
breezes,  die  of  the  same  disease.  The  multiplicity  of  cases  occur  in  sum- 
mer and  in  the  heated  term  with  cool  nights.  A  farmer  bruised  his 
thumb-nail  and  pulled  turnips  in  a  frosted  field ;  he  died  of  tetanus."  The 
other  letters  I  have  received  are  in  substance  very  much  like  that  of  Dr. 
Stilwell,  and  none  of  them  suggest  that  the  disease  is  as  frequent  as  it  is 
generally  supposed  to  be.  Dr.  Benjamin,  of  Riverhead,  says  :  "  I  have 
practised  thirty  years  in  this  village,  have  an  average  of  about  one  case 
each  year  (others  claim  twice  that  number),  and  should  think  the  other 
physicians  in  the  Assembly  District  would  average  about  the  same ;  if  so, 
it  would  make  nineteen  cases  each  year  with  a  population  of  19,000. 
My  opinion  is  that  there  has  been  no  marked  change  in  the  past  forty 
years  as  to  its  frequency  or  fatality.  A  very  large  proportion  of  our 
cases  prove  fatal  in  from  one  to  three  days.  Of  trismus  uascentium  I 
have  had  six  cases  during  the  past  thirty  years,  all  of  which  were  fatal." 
The  information  that  I  have  derived  from  popular  sources  is,  however, 
somewhat  contradictory.  I  learn  that  about  Good  Ground,  which  is 
nearly  twenty  miles  west  of  Sag  Harbor,  there  are  times  when  traumatic 
tetanus  is  very  common  ;  and  it  is  not  safe  for  any  person  who  has  re- 
ceived even  the  most  trivial  injury  to  remain  in  the  neighborhood. 

Capt.  Foster  and  Capt.  Joseph  Penny,  of  Ponquogue,  which  is  upon 
the  sea-coast,  state  that  they  have  known  of  tetanus,  which  was  very  com- 
mon at  certain  seasons ;  several  of  their  friends  have  died,  and  others 
have  moved  temporarily  from  the  place  as  soon  as  injured.  It  was  not 
uncommon  for  women  about  to  be  confined  to  leave  the  locality ;  and 
cases  of  trismus  neonatorum  were  of  quite  frequent  occurrence.  One  man 
whose  foot  had  been  crushed  by  a  horse  died  in  a  few  days. 

From  Mr.  Wells,  of  Quogue,  I  ascertained  that  the  disease  is  confined 
almost  entirely  to  the  district  extending  from  Moriches  to  East  Hampton, 
and  that  at  the  extreme  easterly  end  of  the  Island  (Montauk  Point)  no  case 
has  been  known  to  occur.  So  perfect  is  the  immunity  at  this  place,  that 
colts  are  taken  there  to  be  castrated  and  not  removed  until  the  wound 
is  healed.  The  disease  is  more  common  during  the  fall  than  at  any  other 
season.  Mr.  Wells  has  known  of  from  twenty  to  twenty-five  cases,  mostly 
men  and  boys,  in  a  district  forty  miles  long,  during  the  past  five  years. 
In  this  region  castrated  colts  generally  die  soon  after  the  operation.  In 
one  case,  of  which  my  informant  knew,  a  man  was  shooting  ducks  in  a 
battery ;  his  shot-gun  accidentally  went  off,  the  charge  removing  about 
one-half  of  the  great  toe.  The  wound  was  not  especially  painful,  but  at 
the  end  of  eight  days  convulsions  began,  and  he  died  in  thirty-six  hours. 

Mr.  White,  of  South  Hampton,  scratched  his  thumb  with  a  briar  in  the 


576 


DISEASES    OF    THE    SPINAL    CORD, 


field,  and  afterwards  died.  Mr.  Hand,  of  Canoe  Place,  died  after  a  slight 
injury  to  the  ankle.  Mr.  Wells  also  told  me  that  several  eases  followed 
■wounds  received  in  the  field  where  a  form  of  shell-fish  known  as  the 
"  horse  shoe  "  (king-crab")  is  used  for  manure.  By  the  fall  these  craw- 
fish have  undergone  advanced  decomposition,  and  their  long  spines,  which 
project  in  any  direction,  are  very  apt  to  wound  the  bare-footed  field  hand. 
These  statements  are  entitled  to  some  credence,  for  the  doctor  was  very 
often  not  called  in.  At  the  eastern  end  of  the  island  several  cases  of 
fatal  tetanus  within  a  very  short  time  occurred  in  the  practice  of  Dr. 
Trudeau,  then  of  Little  Neck.  Along  the  Atlantic  sea-board  I  am  told 
that  this  disease  is  by  no  means  uncommon,  and  that  on  the  Southern 
sea-coast  it  is  much  more  frequently  met  with  than  in  higher  latitudes 
In  a  very  interesting  communication  from  Dr.  Fiudlay,  of  Havana,  he 
mentions  a  case  in  which  the  application  of  a  blister  in  a  case  of  pleurisy 
was  followed  by  fatal  tetanus.  The  accompanying  map  will  enable  the 
reader  to  perceive  the  geographical  distribution  of  endemic  tetanus  on 
Long  Island,  the  dark  spots  showing  the  limit  of  the  region,  and  the 
points  where  it  prevails  to  the  greatest  extent. 


Fig.  58. 


Map  of  Suffolk  CorsTT,  Lono  Island.— 1.  Manor.  2.  Riverhead.  3.  Sag  Harl>or.  4.  Ea«t 
Hampton.  5.  South  Hampton.  6.  Ponquogue  and  Good  Ground.  7.  Quogue.  8.  West  Hampton 
9.  East  Moriches.  10.  Centre  Moriches.  11.  Seatuck.  12.  Greenport.  13.  Moutauk  Point.  14. 
Bridge  Hampton.    Darkest  spots  indicate  points  of  greatest  prevalence. 

Cold  climates  have  something  to  do  with  the  production  of  tetanus,  as 
we  would  infer  from  Dr  Kane's  statement  that  intense  cold  produced 
"  an  anomalous  spasmodic  aftectiou  allied  to  tetanus,"  which  aflected 
most  of  his  party,  destroyed  two  men,  and  killed  all  his  dogs.  Trismus 
neonatorum  is  supposed  by  Vogel^  to  depend  upon  the  formation  of  the 
cicatrix  when  the  umbilical  cord  is  roughly  handled,  and  there  is  probably 
pressure  of  some  nerve  by  the  contraction  of  the  cicatrix. 

'  Diseases  of  Children,  p.  65.     Translation  bj  Raphael,  X.  Y.,  1S70. 


TETANUS.  377 

Frost-bite  may  sometimes  give  rise  to  tetanus,  and  the  following  cases 
are  examples  of  this  kind : 

They  occurred  under  the  care  of  Dr.  Bethune,  of  Toronto.  The  first 
was  that  of  a  farmer  who  was  exposed  to  intense  cold  for  about  three 
hours  while  driving.  His  feet  and  fingers  became  severely  frost-bitten 
without  his  becoming  aware  of  the  fact  until  he  arrived  home.  On  ad- 
mission to  the  Toronto  General  Hospital,  four  days  later,  the  toes  and 
the  greater  part  of  both  feet  were  found  in  a  condition  of  moist  gangrene. 

The  fingers  and  parts  of  both  hands  on  the  dorsal  surface  were  black 
and  dry.  Four  days  after  admission  he  was  seized  with  tetanic  symp- 
toms, which  rapidly  developed.  Chloral  hydrate  in  thirt3^-grain  doses, 
with  extract  of  Calabar  bean  in  one-fourth-grain  hypodermic  doses,  until 
five  grains  had  been  given,  failed  to  combat  the  disease,  and  the  patient 
died  in  thirty  hours  after  the  accession  of  the  attack. 

The  second  case  was  that  of  a  man  who,  having  lain  out  in  a  barn  all 
night,  had  both  feet  severely  frost-bitten,  subsequently  becoming  partially 
gangrenous.  In  this  case  trismus  set  in  nine  days  after  exposure,  and 
soon  developed  into  well-marked  tetanus,  to  which  the  patient  succumbed 
in  about  thirty  hours.^ 

Morbid  Anatomy  and  Pathology. — The  older  writers  have 
written  a  great  deal  in  regard  to  the  morbid  anatomy  of  tetanus ;  but 
the  collected  facts  throw  no  light  upon  the  pathology,  and  are  to  a  great 
degree  valueless. 

Lockhart  Clark ^  in  1865  found  in  six  cases  that  there  was  degener'i- 
tion  of  the  gray  substance  of  the  cord.  "  The  first  case  was  reported  at 
some  length,  and  the  lesion  was  found  more  or  less  from  the  origin  of  the 
second  cervical  nerves  to  the  lumbar  enlargement.  At  the  second  cervi- 
cal nerve,  streaks  and  irregular  areas  of  disintegration  were  observed  in 
different  parts  of  the  gray  substance,  and  particularly  around  the  central 
canal,  on  the  right  side  of  which  was  a  space  of  considerable  size  con- 
taining a  finely  granular  fluid,  with  the  debris  of  blood-vessels  and  nerves. 
The  posterior  and  lateral  white  columns,  especially  along  the  edge  of 
the  various  fissures  which  transmit  blood-vessels,  were  damaged  in  a 
similar  way,  and  in  some  sections  the  deeper  portions  of  the  posterior 
columns  which  rest  upon  the  transverse  commissure  were  softened  to  a  con- 
siderable degree.  This  disintegration  was  still  more  marked  in  the  cervical 
enlargement,  chiefly  behind  and  at  the  sides  of  the  canal.  The  posterior 
commissure  was  wholly  and  the  anterior  partially  destroyed  by  a  fluid 
transparent  and  granular  area.  Throughout  the  cervical  enlargement 
similar  lesions  were  discovered,  varying  from  a  state  of  softening  to  one 
of  complete  solution,  and  diminishing  at  intervals  or  almost  disappearing, 
to  return  shortly  in  the  same  form.  At  the  upper  part  of  the  dorsal 
region  the  shape  of  the  cord  was  much  altered,  and  extensive  lesions  of 
the  same  kind  were  everywhere  seen.     In  both  lateral  halves  of  the  gray 


1  London  Lancet,  March,  1875. 

2  Med.-Chir.  Trans.,  1848  and  1865,  and  Med.  Times  and  Gazette,  1865. 


378  DISEASES    OF    THE    SPINAL    CORD. 

substance,  the  left  lateral  columns,  the  right  antero-lateral  column,  the 
superficial  portion  of  the  anterior  columns,  and  iu  the  posterior  columns 
similar  ap])ea ranees  were  found.  Below  this  point  there  was  less  disease 
as  far  as  the  fourth  dorsal  vertebra.  Here,  in  addition  to  the  areas  of  dis- 
integration, large  extravasations  of  blood  were  found  along  the  whole 
lateral  part  of  the  gray  substance  on  both  sides  of  some  sections,  in  one 
side  only  of  others ;  while  the  lumbar  region  manifested  the  same  lesions 
as  the  cervical." 

Dr.  James  Tyson  ^  has  detailed  two  cases  in  which  softening  of  the  pos- 
terior columns  occurred.  In  one  of  these  there  was  extravasation  of  blood 
in  the  po-terior  columns,  and  to  some  extent  from  the  vessels  of  the  pia 
mater.  The  central  gray  commissure  was  destroyed.  In  the  other  case 
no  extravasation  was  found  in  the  posterior  columns,  but  there  was  venous 
congestion  of  the  dura  mater.  I  was  presented  by  Prof  L.  McLane  Tif- 
fany, of  Baltimore,  with  a  piece  of  the  cord  of  one  of  his  patients  who 
had  died  with  tetanus  following  a  severe  burn-  The  pia  mater  was  greatly 
thickened,  and  the  small  posterior  arteries  were  enlarged.  Throughout 
the  section,  which  was  viewed  at  first  with  a  low  power  objective,  I  per- 
ceived a  rather  extensive  increase  of  the  neuroglia.  The  anterior  nerve- 
roots  appeared  to  be  very  well  defined.  Throughout  the  white  and  gray 
matter  there  was  visible  numerous  round  cells  quite  translucent  and 
bright,  which  resembled  somewhat  colloid  bodies.  These  were  more 
plentiful  in  the  posterior  column.  The  vessels  of  the  gray  matter  were 
all  more  or  less  enlarged,  and  some  of  them  were  surrounded  by  spaces 
which  were  considerably  wider  than  the  diameter  of  the  vessel.  The  cells 
of  the  anterior  coruua  were  quite  disintegrated,  and  some  had  taken  an 
oval  form.  Those  that  could  be  recognized  were  found  to  have  broken 
processes,  and  many  had  granular  contents.  The  nerve- trunks  were  un- 
aflfected. 

Arlong^  and  Tripier,  Erichsen,  and  Bouillaud  found  that  the  end  of  the 
nerve  in  the  wound  was  diseased,  and  Lepelletier^  and  Froriep*  discovered 
in  one  case  that  the  neurilemma  of  the  nerves  in  the  vicinity  was  the  seat 
of  inflammatory  changes,  which  extended  from  the  periphery  to  the  cord. 
This  latter  appearance  indicates  an  exceptional  condition  of  affairs,  and 
as  for  the  nerve  change  in  the  wound,  it  is  not  to  be  wondered  at,  for  if 
there  is  any  importance  to  be  attached  to  the  circumstance  of  the  morbid 
appearance  of  an  injured  nerve,  it  is  certainly  inconsiderable  when  we 
consider  how  frequent  must  be  such  a  pathological  condition,  and  still 
there  is  not  a  proportionate  amount  of  tetanus. 

Dr.  R.  ^y.  Araidon,^  has  lately  published  very  full  notes  upon  a  case 
of  tetanus,  which  throw  some  light  upon  the  question  of  morbid  anatomy. 
In  this  observation  the  disease  followed  an  injury  of  the  median  nerve, 

1  The  Practitioner,  August,  1877.  ^  Archives  de  Physiol.,  etc,.  1870. 

^  Kevue  Me-Jicale,  iv.,  1827.  *  Neue  Xotizen,  1837. 

'  Some  new  points  on  the  Path.  Anatomy  of  Tetanus,  Archives  of  Medicine, 
June,  1879. 


TETANUS.  379 

and  the  patient  died  five  days  afterwards.  Microscopical  examination 
revealed  a  variety  of  interesting  meningeal,  vascular  and  other  lesions 
— those  claiming  our  attention  chiefly  being  the  presence  of  vacuoles  in 
the  medulla  and  very  decided  changes  in  the  region  of  the  spinal  acces- 
sory root-fibers  especially,  while  the  vagus,  hypo-glossal  and  glosso- 
pharyngeal nerves  were  found  to  be  the  seat  of  vascular  lesions.  The 
symptoms  pointing  to  implication  of  these  nerves  were  quite  pronounced. 

Our  knowledge  of  the  pathology  of  tetanus  is  based  almost  entirely 
upon  the  experiments  of  physiologists,  and  we  are  left  somewhat  in  the 
dark  as  to  1  he  questions  :  1.  Whether  it  is  a  central  disease  resulting 
from  a  morbid  peripheral  irritation  which  is  reflected  upon  the  cord. 
2,  Whether  it  is  a  central  disease  per  se,  and  the  appearances  noted  after 
death  are  primary.  3.  Whether  the  morbid  changes  are  secondary  to  the 
symptoms,  and  due  to  mechanical  causes. 

We  have  so  far  been  taught  how  general  spasm  may  be  produced. 
Mitchell^  and  Morehouse  caused  in  animals  very  violent  convulsions  by 
injecting  into  the  vertebral  canal  a  half  ounce  of  fluid,  and  very  hot  or 
very  cold  water  seemed  to  aggravate  the  spasms.  Cold  applied  to  the 
spine,  whether  produced  by  the  rhigoline  spray  or  by  ice,  gave  rise  to 
the  same  phenomena.  Cold  to  the  medulla  caused  the  animal  to  topple 
backward. 

Upon  examination  the  vessels  were  found  to  be  intensely  congested. 
So  far,  we  are  furnished  with  the  first  link  in  our  chain.  Assuming  that 
the  spasmodic  movements  are  due  to  a  congestion  of  the  cord,  and  con- 
ceding that  pathological  anatomy  has  furnished  us  in  nearly  every  instance 
with  evidence  of  congestion  of  the  gray  matter,  we  are  to  discover  what 
is  the  factor  of  such  congestion.  It  may  depend  upon  a  reflected  impres- 
sion transmitted  to  the  vaso-dilators,  or  it  may  depend  upon  local  irrita- 
tion by  impure  blood  which  produces  secondary  hypersemia.  In  strych- 
nine poisoning,  the  symptoms  of  which  resemble  those  of  tetanus  very 
closely,  the  spasmodic  phenomena  are  undoubtedly  due  to  the  imperfect 
oxygenation  of  the  blood  ;  consequently  the  cord  is  supplied  with  blood 
loaded  with  carbonic  oxide.  It  seems  to  me  very  possible  that  the 
same  condition  of  affairs  exists  in  tetanus ;  that  there  may  be  direct  irri- 
tation of  the  nervous  matter  of  the  cord  dependent  upon  some  primary 
blood  condition. 

Fox^  very  clearly  expresses  himself  as  follows  :  "  The  abnormal  blood 
imperfectly  nourished  the  cord.  An  imperfectly  nourished  cord  is  ipso 
facto  an  excitable,  an  impressible  cord  ;  this  impressibility  renders  arte- 
rial spasms  abnormally  facile,  whether  the  exciting  cause  is  the  circula- 
tion in  the  cord  of  more  of  the  morbid  blood,  or  reflected  irritation  from 
a  diseased  nerve  at  the  periphery,  or  reflex  irritation  from  any  other 
cause  and  from  any  other  point  in  the  body,  and  if  this  arterial  contrac- 
tion goes  on  for  any  protracted  period,  or  is  frequently  repeated,  we  may 


^  Am.  Journ.  Med.  Sciences,  1866.  ^  Op.  ci'.,  p.  362. 


380  DISEASES    OF    THE    SPINAL    CORD. 

find  various  lesions  due  to  imperfect  blood-supply  in  addition  to  those  due 
to  diminished  nutrition  from  the  original  nature  of  the  blood,  while,  as  a 
sequence  of  the  spasmodic  arterial  contractions,  we  get  hypertemia,  and 
perhaps  exudation,  and  lastly  the  pressure  of  the  exudation  or  some 
peculiarity  in  its  nature  may  lead  to  some  disintegration  of  the  nervous 
centres." 

This  theory  seems  to  me  to  be  tenable  for  several  reasons:  1,  Inju- 
ries of  peripheral  nerves  are  common,  and  the  cases  of  resulting  tetanus 
are  out  of  all  proportion  to  those  presenting  no  subsequent  nervous  symp- 
toms. 2.  Its  endemic  nature,  its  prevalence  in  certain  districts  and  its 
not  uncommon  idiopathic  origin  when  there  is  no  ascertained  eccentric 
cause.  3.  The  appearances  of  the  cord  are  of  a  destructive  character, 
and  it  is  a  matter  of  doubt  whether  they  are  not  more  a  result  than  a 
cause. 

Considerable  discussion  has  taken  place  in  regard  to  the  cause  of  the 
high  elevation  of  temperature.  Yerneuil  does  not  consider  it  due  either  to 
myelitis  of  the  superior  part  of  the  cord,  or  to  asphyxia  or  muscular  con- 
tractions ;  but  Mason  is  decidedly  of  the  opinion  that  such  increase  in 
temperature  is  alone  the  result  of  muscular  action.  The  experiment  of 
Mason  has  shown  that  the  temperature  of  a  tetanized  muscle  is  often 
increased  from  one  to  two  degrees. 

The  medulla  has  been  found  to  be  the  seat  of  grave  lesions,  such 
as  in  Araidon's  case  for  example,  and  it  is  probable  that  the  trismus 
and  other  evidences  of  an  excited  state  of  cranial  nerve  innervation, 
which  occur  in  the  beginning,  are  indications  of  primary  disturbances 
in  the  bulb. 

Diagnosis. — The  diseases  and  conditions  with  which  tetanus  may  be 
confounded  are  hydrophobia,  strychnine  poisoning,  hysteria,  and  acute  spinal 
meningitis.  In  the  first  there  is  no  risus  sardouicus ;  the  convulsions  are 
clonic  ;  there  is  the  noisy  hawking  and  effort  to  spit ;  the  dread  of  water, 
the  delirium,  and  finally  the  history  of  a  bite  by  a  rabid  animal,  which, 
however,  is  not  always  ascertained.  Strychnine  poisoning  is  very  easily 
mistaken  for  tetanus.  In  poisoning  by  a  large  dose  of  the  alkaloid  the 
symptoms  appear  rapidly,  and  death  takes  place  in  a  short  time.  The  hands 
are  clenched  and  rigid,  but  the  jaw  can  be  opened,  which  is  not  possible  in 
tetanus-  This  resemblance  between  the  two  conditions  has  been  made 
use  of  in  more  than  one  poisoning  ca.se  as  a  ground  of  defence,  and  in 
that  of  Cooke,  who  was  poisoned  by  Palmer,  the  question  was  narrowed 
down  to  the  appearance  of  the  cord.  Cases  of  hysteria  sometimes  present 
symptoms  which  not  rarely  counterfeit  those  of  tetanus.  The  jaw  may 
be  locked,  but  there  will  be  few  of  the  other  features.  Hysterical  pa- 
tients are  nearly  always  seemingly  unconscious,  and  there  are  no  evi- 
dences of  suffering  whatever.  In  spinal  meningitis  the  muscular  rigidity 
seems  to  be  dependent,  in  a  great  measure,  upon  the  patient's  efforts  to 
relieve  the  pain  which  is  produced  by  an  uncomfortable  position.  The 
locked  jaw,  which  is  an  early  symptom  of  tetanus,  is  absent  in  acute  spi- 
nal meningitis. 


TETANUS.  381 

Prognosis. — Dr.  Jones  ^  has  collected  480  cases  of  tetanus,  213  of 
wliicli  recovered  under  treatment,  the  mortality  being  49.2  per  cent.,  or 
one  death  in  2.02.  These  were  all  cases  of  traumatic  tetanus.  The  per- 
centage of  death  in  the  British  army  during  the  Crimean  War  was  91  per 
cent. ;  and  Baron  Larrey's  estimate  of  mortality  of  the  French  army  under 
Napoleon  was  at  about  the  same  rate. 

In  regard  to  the  time  of  death  Dr.  Jones  found  that  of  50  cases,  in 
which  the  disease  followed  slight  injury  of  the  extremities,  43  proved 
fatal  in  a  short  time,  and  of  the  whole  number  of  deaths  reported  24.14 
per  cent,  ran  a  rapid  course  after  slight  injuries,  and  terminated  in  death 
in  a  few  days.  One  case  died  on  the  second  day.  Cases  are  reported 
which  have  terminated  fatally  in  twenty-four  hours  after  the  appearance 
of  symptoms.  In  one  case,  mentioned  by  Dazelle,  they  appeared  on  the 
third  day,  and  the  patient  died  the  same  night.  One  author  lays  stress 
upon  the  statement  that  the  prognosis  is  governed  by  the  interval  that 
elapses  between  the  receipt  of  the  wound  and  the  appearance  of  the 
symptoms,  and  that  the  longer  this  interval  is  the  more  favorable  are  the 
patient's  chances.  Many  writers  agree  that  elevated  temperature  plays 
an  important  part  in  the  prognosis,  and  that  any  increase  is  to  be  looked 
upon  with  alarm.  The  duration  of  the  attack  is  to  be  taken  into  account, 
and  every  day  bridged  over  by  the  patient  after  the  fourth  or  fifth  in- 
creases his  chances  of  recovery.  Of  course  the  gravity  of  the  affection 
depends  much  upon  the  violence  of  the  paroxysms. 

Treatment. — It  would  be  useless  to  discuss  the  merits  of  the  many 
drugs  that  have  been  brought  forward  from  time  to  time.  Our  most  effi- 
cacious remedial  agents  are  the  depresso-motors,  and  among  these  may  be 
mentioned  chloroform,  chloral  hydrate,  Indian  hemp.  Calabar  bean,  and 
conium. 

Calabar  bean,  which  has  enjoyed  a  deserved  popularity,  has  been  made 
use  of  with  great  success  by  Eilert,  Holhouse,  Wood,  Watson,  and  a  host 
of  others.  Holhouse  in  1864  reported  two  cases,  one  of  which  was  cured 
after  having  taken  3-4?  grains  of  the  extract  every  two  hours.  Ashdown 
was  not  so  successful,  and  Spencer  and  Dickenson  had  the  same  discourag- 
ing experience.  Even  Watson  was  one  of  the  first  to  use  the  remedy, 
and  three  out  of  his  four  cases  of  tetanus  were  cured  by  the  administra- 
tion of  ten  drops  of  the  tincture  every  hour,  and  by  a  subsequent  increase 
in  the  dose.  The  drug  may  be  given  in  full  doses,  say  from  one-quarter 
to  one-third  of  a  grain  of  the  extract  every  two  hours. 

The  chloral  treatment  has  certainly  been  more  efficacious.  Surgeon- 
Major  Hunter'^  reported  two  cases :  one  a  boy,  and  the  other  a  man  of  40. 
In  the  first  case  chloral  was  combined  with  cannabis  indica.  R.  Tr.  can- 
nabis ind.  1T(,x  ;  potass,  bromid.  gr.  v,  every  third  morning ;  and  chloral 
hydrat.  gr.  xij,  three  times  a  day,  together  with  inhalations  of  chloroform 


^Medical  and  Surgical  Memoirs,  vol.  i.,  New  Orleans,  1876. 
2  Indian  Med.  Gaz.,  Feb.  1,  1875. 


382  DISEASES    OP    THE    SPINAL    CORD. 

as  required.  The  other  patient  took  20  grains  of  the  chloral  thrice 
daily.  Opium  and  chloral  in  combination  have  perhaps  been  more  ef- 
fective than  the  chloral  alone,  and  Delsal  ^  saved  three  cases  out  of  four 
by  this  treatment.  H.  C.  Wood  reports  9  cures  by  chloral  out  of  18 
cases. 

Chloroform  has  not  proved  to  be  the  valuable  remedy  that  many  have 
supposed  it  to  be,  and  it  has  only  the  power  to  "  crowd  down  the  bad 
symptoms  which  burst  forth  usually  with  additional  fury  when  the  narcosis 
subsides." 

Aconite  has  been  of  service  upon  many  occasions.  It  was  lirst  used  by 
Page'^  in  a  case  of  traumatic  tetanus.  The  toxic  effects  of  the  drug  were 
produced,  and  during  their  continuance  there  was  a  remission  of  symptoms. 
The  patient  was  first  reduced  to  a  condition  bordering  on  syncope,  and  af- 
terwards stimulated.  De  Morgan  and  others  cured  tetanus  with  this  reme- 
dy, and  its  place  in  the  therapeutics  of  the  affection  is  by  no  means  an  in- 
ferior one.  The  pulse  is  markedly  lowered,  the  muscular  rigidity  relaxed 
and  a  condition  cf  akinesis  and  prostration  takes  the  place  of  the  irritable 
nervous  state.  Curare,  nitrite  of  amyl.  and  belladonna,  as  well  as  a  host 
of  remedies  of  the  same  character,  have  been  praised  from  time  to  time ; 
but  most  of  them  are  useless.  Chloral  hydrate,  either  in  combination 
with  aconite,  or  chloroform,  and  cold  to  the  spine,  which  may  be  applied 
by  the  ether  spray  as  recommended  by  Carpenter,  I  think  is  the  best 
form  of  treatment,  and  should  be  resorted  to  as  early  as  possible.  If 
these  remedies  fail,  Calabar  bean,  hyoscyamin,  curare,  or  nitrite  of  amyl 
may  be  tried,  and  conium,  which  is  a  powerful  depressor  of  spinal  exci- 
tability, may  be  given  a  trial.     Warm  baths  have  been  recommended. 

"Dr.  F.  Franzolini^  relates  a  case  of  tetanus  arising  fi'om  exposure  by 
sleeping  on  the  damp  ground  after  great  fatigue,  successfully  treated  by 
prolonged  warm  baths  and  the  continual  use  of  chloral  and  morphia. 
The  chloral  was  given  frequently  by  the  stomach,  and  the  morphia  by 
subcutaneous  injection.  The  first  bath  was  for  six  hours,  at  a  tempera- 
ture of  40^^  C.  (104°  F.),  and  subsequent  ones  lasted  five,  four,  three,  or 
two  hours.  This  treatment  was  carried  out  from  the  18th  to  the  80th  of 
the  mouth  ;  but  the  daily  use  of  chloral  and  morphia  was  continued  some 
time  longer.  Of  the  first  ninety  hours  of  his  disease,  the  patient  passed 
forty-eight  in  the  bath  at  40^  C.  In  twenty-nine  days  he  consumed  nearly 
four  ounces  of  chloral  hydrate,  and  about  twenty-two  grains  of  hydro- 
chlorate  of  morphia  were  injected.  Although  kept  so  long  in  a  state  of 
almost  constant  narcotism,  the  mental  powers  of  the  patient  were  in  no 
way  affected." 

H.  de  Renzi,*  of  Genoa,  has  spoken  highly  of  the  dark-room  treatment. 
His  patient  was  kept  absolutely  quiet.     He  ascribes  the  success  to  the 

'  Quoted  in  Practitioner,  August,  1877. 

^  Lancet,  April  4,  1846. 

3  The  Doctor,  Oct.  1,  1875.     Abs.  in  Phila.  Med.  Times,  Oct.  30,  1875. 

*  Gaz.  Med.  de  Paris,  No.  32,  1877. 


1 


TETANUS.  383 


belief  that  the  absorption  of  oxygen  and  elimination  of  carbonic  oxide 
are  impeded  by  darkness. 

The  other  indications  seemed  to  be  perfect  quiet,  and  during  and  after 
the  attack  ample  nourishment.  Xiemeyer^  believas  in  clysters  containing 
twenty  or  thirty  drops  of  laudanum.  He  also  recommends  chamomile 
baths  in  the  infantile  variety. 


1  Text-Book  of  Pract.  Med.,  vol.  ii.  p.  352. 


384:  BULBAR    DISEASES. 


CHAPTER   XIII. 

BULBAR  DISEASES. 
EPILEPSY. 

Synonyms. — L'Epilepsie  (Fr.) ;  Fallsucht  (Ger.) ;  Mai  caduco 
(Ital.\ 

Definition. — This  most  familiar  of  all  nervous  diseases  is  character- 
ized b)'  loss  of  consciousness  of  variable  duration,  attended  or  unattended 
by  either  slight  muscular  spasms  or  general  convulsions. 

The  relation  of  these  two  elements,  the  psychical  and  physical,  is  not 
alwavs  the  same,  as  in  some  forms  of  the  disease  there  is  a  momentary 
loss  of  consciousness  and  perhaps  no  appreciable  spasm,  or  the  two  may 
co-exist,  there  being  protracted  loss  of  consciousness  and  violent  convul- 
sions. There  are  sometimes  very  peculiar  combinations  of  symptoms 
which  will  receive  mention  hereafter. 

The  modern  investigation  of  epilepsy  by  Hughlings  Jackson  has  mate- 
rially modified  our  views  of  the  disease.  His  consideration  of  the  patho- 
logy of  the  disease  is  exceedingly  complex,  and  he  is  inclined  to  treat 
the  subject  with  greater  breadth,  and  give  it  greater  importance  than  it 
ever  has  received.  A  disruption  of  the  most  transient  description  of 
the  harmonious  relation  of  the  psychical  centres  gives  rise  to  a  genuine 
paroxysm  or  discharge,  so  that  many  temporary  bizarre  actions  which 
most  of  us  indulge  in  even  in  comparative  health,  become  invested  with  a 
new  significance.  Certain  phases  of  what  we  indefinitely  call  "  absent- 
mindedness,"  leading  us  to  commit  absurd  acts  which  we  laugh  at  after 
they  are  performed,  may  be  in  reality  genuine  epilepsies,  and  in  others 
may  attain  the  importance  of  disease  symptoms. 

The  scope  of  this  work  does  not  permit  me  to  consider  the  history  of 
the  disease  ;  suffice  it  to  say,  that  its  antiquity  dates  back  to  the  days  of 
Hippocrates  and  Aretjeus,  and  biblical  references  to  its  existence  are 
common. 

Cook ^  thus  speaks  of  the  early  writings:  "Epilepsy  has  been  distin- 
guished by  a  great  variety  of  names  such  as  morbus  sacer,  comitialis  her- 
culeus,  caducus,  etc.  Aretseus  says,  it  may  have  been  called  sacred  on 
account  of  the  magnitude  of  the  evil,  it  being  customary  to  call  what  is 
great  by  that  name;  or  because  it  is  to  be  cured  rather  by  the  Divine 
than  by  human  power,  or  because  persons  laboring  under  it  have  been 
thought  possessed  by  demons.^     .  .     Some  of  the  ancients  were  of 

1  Treatise  on  Nervous  Diseases,  Am.  ed.,  1824,  p.  326. 
*  Aret.  lie  Caus-  et  Sign.  Morb.,  lib.  i.  c.  4. 


EPILEPSY.  385 

opinion  that  epilepsy  was  denominated  the  Herculean  disease  because 
Hercules  was  subject  to  it ;  but  Galen  says,  it  was  so  called  on  account 
of  its  form  or  magnitude." 

"Epilepsy  was  denominated  morbus  comitlalis,  either  because  it  fre- 
quently occurred  in  the  crowded  assemblies  of  the  Romans  called  comitla, 
m  which  the  passions  of  the  people  were  often  much  excited,  by  which  it 
might^  be  occasioned,  or  because  it  was  customary  to  dissolve  the  comliia 
if  during  the  sitting  any  person  should  be  affected  by  it. 

"  The  application  of  the  term  caducus,  a  falling  sickness,  is  too  evident 
to  need  illustration." 

In  our  description  of  the  affection  it  is  impossible  to  make  any  well- 
defined  division  ;  suffice  it  to  say,  that  all  writers  recognize  forms  known 
as  Rant  mal  or  Epilepsia  gravior,  and  Petit  mal  or  Epihpsia  milior. 
Reynolds  divides  the  latter  into  two  varieties,  viz.:  1st.  A  form  with  evi- 
dent spasms,  and  another  without  evident  spasms.  Besides  these,  various 
irregular  forms  have  been  included,  such  as  masked  epilepsy  and  hystero- 
epilepsy. 

THE   GRAVE  ATTACK. 

^  Symptoms. — The  most  familiar  variety  is  known  as  Epilepsia  gra- 
vior, and  it  may  be  described  as  an  attack  expressed  in  four  stages  :  1st. 
A  premonitory  stage ;  2d.  Stage  of  convulsion  ;  3d.  Stage  of  subsidence  ; 
and  4th.  A  stage  of  stupor,  or  "  after-stage  "  (Reynolds).  The  first  stage 
may  often  be  absent,  for  in  many  cases  there  is  a  sudden  debut;  but*if 
such  be  not  the  case,  the  patient  may  have  well  recognized  warnings  which 
may  be  either  psychical  (mental  or  emotional),  motorial,  sensorial,  or 
vascular,  these  latter  being  objective  indications.  Though  these  warn- 
ings are  spoken  of  by  many  patients,  it  is  almost  impossible  to  rely  upon 
their  testimony,  as  the  demoralization  dependent  upon  the  anticipation 
of  the  attack,  or  the  short  duration  of  such  premonitory  symptoms,  is 
sufficient  to  prevent  them  from  analyzing  their  feelings.  It  i^,  however, 
possible  in  many  instances  to  collect  information  from  a  number  of  cases 
which  shall  be  a  basis  fur  the  general  classification  of  premonitory 
symptoms. 

Very  often  the  attack  will  be  immediately  preceded  by  a  vague  dread, 
or  an  undefined  fear  of  some  impending  trouble. 

In  one  of  my  cases— a  remarkably  clever  and  intelligent  young  Iddy — 
there  is  a  condition  of  exhilaration  of  spirit,  and  a  mental  activity  which 
lasts  for  some  hours.  Although  deeply  under  the  iofluence  of  the  bro- 
mide, she  will  come  out  of  her  apathetic  state  and  chat  with  her  friends 
upon  all  subjects  in  the  most  entertaining  manner.  Twitching  of  the 
eyelids  or  of  the  lower  extremies,  vertigo  with  rotatory  movement,  and 
tremor  are  examples  of  the  disorders  of  the  motility  which  occasionally 
precede  the  attack.  Sometimes  there  is  aa  elevated  sensitiveness  of  the 
organs  of  special  sense. 

Hallucinations  of  hearing  and  visual  hallucinations  are  not  uncomn>on. 
One  of  my  patients  has  often  seen  a  fiery  cross;  and  another  refers  to  a 
25 


386  BULBAR    DISEASES. 

locomotive  with  a  glaring  headlight,  which  rushes  upon  him,  while  a 
third  hears  voices ;  and  in  two  cases  the  patients  say  that  they  "  smell 
smoke."      Morbid  sensations,  which  cannot  be  defined,  are  spoken  of  oc- 
casionally, and  a  vague  sense  of  weight  in  the  epigastrium,  head,  or  some 
other  part  of  the  body  is  a  frequent  precursor  of  the  attack.  Occasionally 
the  peculiar  sensations  begin  at  some  remote  part  of  the  body,  and  seem 
to  move  rapidly  towards  the  head  ;  such  phenomena  are  known  as  aurie. 
These   axme  have  been  compared  to  the  blowing  of  wind  over  the  surface, 
the  creeping  of  insects  upon  the  skin,  or  the  pricking  of  needles.     They 
last  but  a  few  seconds,  and  are  sometimes  perceived,  but   not  always. 
In  the  wards  under  ray  charge  at  the  Epileptic  Hospital,  the  patients 
sometimes  have  perceived  the  aurce  in  time  to  seek  the  nurse  or  attract 
the  notice  of  the  other  patients.      Careful  investigation  of  twenty-nuie 
cases  resulted  in  the  discovery  that  eighteen  of  them  had  a  warnu>g  ot 
some  kind,  four  had  none,  and  the  rest  gave  us  unsatisfactory  answers 
After  a  long  process  of  condensation  of  statements,  I  find  that  seven  had 
an  aura  starting  from  the  epigastric  region,  two  con)plained  of  constric- 
tion of  the  chest,  seven  had  slight  vertigo,  and  one  had  an  aura  starting 
from  the  extremities,  and  in  one  there  was  trembling  of  the  right  hand 
Headache  preceded  the  attack  in  four,  and  the  "  indescribable  feeling  "of 
the  coming  fit  was  alluded  to  by  a  number.     In  one  remarkable  case  the 
first  intimation  of  the  attack  was  the  violent  jerking  of  the  head  to  one 
side  and  a  species  of  vertigo.      In  another  case  the  patient  muttered  in- 
coherently for  a  full  minute  before  the  actual  attack.     A  third  case  was 
equally  curious.     The  patient,  whose  mental  condition  was  good,  would, 
without  any  apparent  reason,  attract  the  attention  of  persons  about  him 
by  the  repetition  of  the  sylables  "  be-lub-be-lub,  be-lub,  lub,  lub-a-lub, 
a-lub,"  pitching  his  voice  in  a  high  key,  and  gradually  lowering  the  tone 
until' the  last  part  of  his  utterance  was  hushed  and  low,  and  then,  after 
giving  vent  to  a  species  of  groan,  he  would  become  convulsed.     Trous- 
seau^ calls  attention  to  the  "  vascular  prodromata."     A  local  determina- 
tion of  blood  may  occur  in  the  finger,  for  instance,   causing  it  to   swell, 
reddening  the  skin,  and  rendering  it  successively,  within  a  very  short 
time  red,  and  of  a  more  or  less  deep  violet  color;  or,  again,   the  skin 
may  become  excessively  pale  after  having  been  injected  for  some  time. 
The  swelling  is  real,  not  apparent ;  for  rings  previously  easy  suddenly 
become  too  tight  for  the  finger.  The  only  premonitory  symptom  may  some- 
times be  an  involuntary  discharge  of  urine.     It  is  difficult  to  distinguish 
this  accident,  however,  and  it  is  very  liable  to  be  considered  a  part  ot  the 
attack,  which  it  may  be  in  reality.     ^Dr.  Hughlings  Jackson  has  made 
a  contribution  of  the  study  of  auric  with  reference  to  localization.     When 
the  epileptic  paroxysm   is  preceded  by  vertigo   with    apparent   rotation 
of  objects,  the  attack  begins  on  the  right  side  and  indicates  a  cortical 
lesion  of  the  opposite  side.    When  the  aur»  consist  in  perception  of  odors, 


1  Clinical  Medicine,  Am.  ed.,  vol.  i.  p.  75.  '  "  Brain,"  July,  18S0. 


EPILEPSY.  387 

or  epigastric  sensation,  or  when  masticatory  movements  of  the  jaw  occur, 
the  convulsions  begin  on  the  left  side. 

2d  Stage  {Stage  of  Convulsion). — lu  many  cases  the  first  indication  of 
the  attack  is  a  wild  cry,  which  startles  those  about  the  patient.  I  have 
seen  a  soldier  marching  in  procession  throw  up  his  gun  and  shriek  so  loud 
as  to  be  heard  half  a  block  away,  and  fall  to  the  pavement  in  a  convul- 
sion. This  shriek  is  a  psychical  manifestation,  and  different  from  another 
form  of  cry  which  the  patient  may  utter.  This  second  variety  is  less 
noisy,  and  is  produced  by  the  forcible  expulsion  of  air  through  the  vocal 
cords  which  follows  spasm  of  the  thoracic  muscles.  It  is  more  a  species 
of  groan.  Simultaneously  there  is  loss  of  consciousness,  and  the  patient 
falls  to  the  ground,  and  is  agitated  by  tonic  contraction  of  all  the  muscles 
of  the  body,  but  usually  those  of  one  side  more  than  the  other  ;  so  that  his 
body  is  twisted  and  bent.  The  muscles  of  the  neck  are  strongly  contrac- 
ted, while  the  face  is  generally  distorted.  The  stronger  contraction  of 
some  muscles  than  others  draws  the  weaker  side  so  that  movements  are 
produced  which  are  not  the  result  of  clonic  contraction,  but  rather  an  evi- 
dence of  unequally  expended  forces/  Respiration  stops,  or  there  may  be 
a  long  expiration,  and  then  stoppage  altogether  for  a  few  seconds.  The 
pulse  is  now  rapid  and  very  small,  a  result,  probably,  of  compression  of 
the  arteries  by  muscular  masses,  and  the  heart-beats  are  strong.  At  the 
end  of  a  few  seconds,  and  rarely  after  a  minute,  the  convulsions  become 
clonic,  the  patient  throwing  his  arms  about  violently,  or  bumping  the  back 
of  his  head  upon  the  floor.  He  is  still  unconscious,  and  may  have  evacua- 
tions from  his  bowels  and  bladder,  or,  as  in  some  of  the  cases  that  I  have 
seen,  there  may. be  an  emission  of  semen.  Reynolds  calls  attention  to 
vomiting,  a  symptom  which  I  have  several  times  witnessed.  The  respira- 
tion now  becomes  labored  and  rapid,  and  there  may  be  snoring.  Froth 
collects  about  the  mouth,  which  may  be  tinged  with  blood,  as  the  patient 
sometimes  bites  his  tongue  or  lips.  The  surface,  which  was  in  the  first 
stage  quite  pale  and  cool,  now  becomes  dusky,  and  of  a  dark  livid  color. 
The  pupils  may  remain  dilated  as  they  were  at  the  onset  of  the  attack,  or 
may  be  unequal.  From  my  note-book  I  find  that  the  following  points 
were  observed  in  the  twenty-nine  cases  previously  alluded  to.  In  twenty- 
six  the  convulsions  were  quite  general.  In  three  the  legs  were  more  con- 
vulsed than  any  other  part.  In  three  the  arms  were  especially  agitated. 
In  one  patient  the  movements  were  confined  to  the  left  side.  The  cry  was 
very  piercing  in  five  instances.  In  three  there  was  only  a  moan  or  gurg- 
ling expiratory  sound.  Twenty -four  of  these  patients  bit  their  tongues. 
In  twenty-three  the  pupils  were  wildly  dilated.  In  two  the  dilation  was 
not  so  marked.  In  four  no  appreciable  difference  was  noticed.  After  the 
stage  of  tonic  convulsion,  which  lasts  a  few  minutes,  the  third  stage  is 
reached.  In  the  large  number  of  cases  the  attack  may  begin  by  local 
convulsive  movements  in  the  hand  or  in  some  of  the  muscles  of  the  face. 
The  thumb  may  be  sharply  turned  in  and  the  fist  clenched — the  convul- 
sion then  becomes  general, 

^  Eeynolds. 


388  BULBAR    DISEASE!?. 

od  Stage  (Stage  of  Subsidence^. — This  is  marked  by  a  gradual  return 
of  consciousness.  The  patient  may  stupidly  turn  his  head  or  look  up- 
wards, the  eyes  having  a  meaningless  expression,  and  the  balls  oscillating 
slightly.  He  may  strive  to  express  himself,  but  only  gives  utterance  to 
a  series  of  unintelligible  sounds.  He  may  make  some  eff)rt  to  rise, 
but  finds  it  impossible  to  do  so.  His  pulse  is  small  and  thready,  or 
sometimes  full  and  bounding,  especially  when  the  first  two  stages  have 
been  short.  His  eyes  are  injected,  and  his  pupils  either  normal  or  con- 
tracted. 

Ath  Stage  (Stage  of  Stupor). — Exhausted  by  his  attack,  he  falls  into  a 
sound  sleep,  which  is  so  profound  that  he  lies  where  he  has  fallen,  and  re- 
sents any  attempt  to  remove  him.  The  stupor  may  be  so  deep,  however, 
as  to  make  him  unmindful  of  what  is  going  on  about  him.  His  sleep 
lasts  for  several  hours,  and  is  characterized  by  snoring.  If  the  patient 
recovers  without  the  stupor,  he  is  very  irritable  and  cross.  He  complaius 
of  headache,  or  perhaps  nausea  and  vomits;  and  his  pulse  is  irritable  and 
irregular.  Thompson'  calls  attention  to  the  tracings  obtained  in  epilepsy 
when  the  heart  is  healthy,  and  it  is  possible  to  obtain  good  results.  He 
as  well  as  Lorain  found  that  the  sphygmograph  tracing  exhibited  a  distinct 
dicrotic  notch. 

In  regard  to  the  time  of  attack,  two  divisions  have  been  made — 7ioc- 
turnal  and  diurnal.  I  have  thought  it  best  to  make  another,  viz.:  ma- 
tutinal. 

Perhaps  nocturnal  epilepsy  is  much  more  common  than  the  other  forms, 
for  a  great  many  patients  never  have  attacks  at  any  other  time,  while 
some  may  have  them  at  all  times,  and  a  few  only  during  the  day.  A 
large  number  are  attacked  just  as  they  awaken  ;  and  I  have  met  this 
form  so  frequently  that  I  prefer  to  use  the  term  matutinal  for  the  attacks 
occurring  between  five  and  nine  in  the  morning.  The  only  sign  of  a  noc- 
turnal attack  may  be  the  evidence  of  involuntary  passages  of  urine  and 
feces,  and  sometimes  both.  Blood  upon  the  bed  linen  as  a  consequence  of 
tongue-biting  is  another  indication,  and  the  trouble  which  is  required  to 
rouse  the  patient  is  a  third.  Of  forty-eight  patients,  fourteen  had  their 
attacks  at  irregular  hours,  seventeen  had  thsra  at  night  only,  five  in  the 
day,  and  twelve  in  the  morning. 

Tlie  patient  may  sometimes  do  himself  bodily  harm  during  the  convul- 
sion and  Dr.  Maury,  of  Memphis,,  has  communicated  to  me  the  following 
two  cases  of  dislocation  of  the  bones  during  an  epileptic  paroxysm.  This 
is  a  rare  accident  in  epilepsy,  although  it  is  not  uncommon  in  tetanus. 

Case  I.  A  man  from  Holly  Springs,  Miss.,  was  sent  to  Dr.  M.  in  Dec. 
1876.  The  patient  was  sixty  years  of  age,  a  planter,  and  of  good  habits. 
About  one  year  before,  after  eating  his  supper,  he  became  ill  and  had 
convulsions.  In  the  night  he  had  fresh  convulsions,  and  suffered  con- 
siderably from  pain  in  the  right  shoulder  The  convulsions  recurred 
at   intervals   of   ten    days.      When    he   was   brought    to   Dr.    M.    the 

1  West  Eiding  Keports,  vol.  ii.  p.  303. 


EPILEPSY.  389 

shoulder  was  found  to  be  shrunken,  and  the  humerus  dislocated  and  im- 
movable. 

Case  II.  A  lady  from  Alabama,  during  the  menopause,  was  affected 
with  epilepsy  about  two  years  and  a  half  before  the  Doctor  saw  her.  She 
was  attacked  at  night  with  convulsions  and  pain  in  left  hip.  These  at- 
tacks occurred  at  intervals  of  from  two  to  four  weeks  before  she  was  seen 
by  a  physician.  Left  lower  extremity  found  to  be  shortened  about  two 
inches,  lemur  evidently  dislocated.  Muscular  contraction  on  outside  of 
leg  ;  toes  everted,  and  thigh  turned  inwards  In  this  case  no  attempt  was 
made  to  reduce  the  dislocation.  Whenever  she  had  convulsions  there  was 
pain  in  region  of  liver. 

THE    LIGHT   ATTACK. 

Symptoms. — The  lighter  forms  of  epilepsy  are  included  under  the 
head  of-  Epilepsia  mitior,  and  are  attended  by  a  very  transitory  loss  of 
consciousness.  There  may  be  little  or  absolutely  no  spasm,  and  the  attack 
may  be  so  unpronounced  as  to  escape  the  notice  of  those  persons  who  may 
happen  to  be  present.  The  patient  may  be  eating  at  the  time,  and  sud- 
denly drop  his  knife  and  fork  ;  or  he  may  be  engaged  in  some  occupa- 
tion, and  suspend  operations  for  a  second.  In  one  of  my  patients  the 
only  indication  of  the  attack  was  the  rolling  upwards  of  the  eyes. 
Another,  a  gentleman,  when  writing  would  stop  for  a  moment  and  go 
on  with  his  work  entirely  unconscious  of  any  interruption.  If  walk- 
ing, there  may  be  a  sudden  loss  of  equilibrium,  but  he  rarely  falls.  The 
face  may  be  blanched  or  flushed  momentarily,  and  the  patient  may 
suffer  no  bodily  discomfort,  but  is  sometimes  restless,  depressed,  or  low- 
spirited. 

An  aggravated  state  may  exist,  in  which  the  muscular  spasms  are  more 
marked. 

The  attacks,  which  have  been  described  as  "  weak  spells,"  or  "  fainting 
fits,"  by  uninfurmed  people,  consist  in  more  protracted  loss  of  conscious- 
ness, accompanied  perhaps  by  strong  muscular  contractions  of  the  muscles 
of  the  face  or  arms,  pallor,  and  dilatation  of  the  pupils.'  I  have  a  patient 
under  observation  who  has  a  distinct  epigastric  aura;  she  then  becomes 
rigid,  holds  her  breath,  grasps  the  arms  of  her  chair;  her  head  is  drawn 
forwards,  and  so  she  remains  for  a  minute  or  two. 

The  foregoing  forms  may  coexist,  there  being  distinct  attacks  of  grand 
mal,  with  repeated  petit  mal  seizures,  which  seem  to  have  no  special  rela- 
tion to  the  more  serious  convulsions.  Twelve  of  the  twenty-nine  cases 
suffered  from  grand  mal  alone,  and  seventeen  had  both  forms,  and  in  these 
cases  the  petit  mal  predominated. 

As  to  periodicity  and  frequency  of  the  attacks  there  is  much  to  be  said. 
There  is  a  peculiarity  in  the  regularity  of  the  seizures  which  is  to  be 
observed  in  very  many  cases.  A  tendency  to  weekly,  semi-monthly,  or 
monthly  recurrence  is  noticed. 

When  the  fits  take  place  there  may  be  only  one  at  a  time,  or  there  may 


390  BULBAR    DISEASES. 

be  a  number  within  twenty-four  hours,  or  two  or  three  days,  and  then  an 
interval  of  the  duration  I  have  just  described  elapses  before  a  fresh  attack 
or  series  of  attacks  takes  place. 

In  Reynolds's  experience  there  are  four  times  as  many  epileptics  who 
have  their  attacks  more  frequently  than  once  a  month  as  there  are  who 
have  them  at  long  intervals ;  but  I  am  disinclined  to  agree  with  him 
"  that  males  are  more  subject  to  monthly  attacks  than  females,  and  that 
attacks  in  the  latter  are  not  as  a  rule  monthly  seizures." 

I  discover  every  day  numerous  verifications  of  the  menstrual  influence. 
In  forty  patients  I  find  that  eighteen  occur  during  or  just  after  the  days 
the  woman  has  her  catamenia ;  and  in  more  than  one  case  much  interest 
arises  from  the  fact  that  there  was  dysmenorrhcea,  and  that  when  this 
was  relieved  the  attacks  disappeared. 

In  many  chronic  cases,  especially  when  there  are  complications,  there 
is  rarely  any  regularity  in  the  appearance  of  the  attacks.  In  the  Epi- 
leptic Hospital,  on  Blackwell's  Island,  I  find  extreme  variation  in  their 
number  ;  and  there  are  patients  under  treatment  who  have  had  but  three 
or  four  attacks  in  one  year,  while  there  are  others  who  generally  have 
from  five  to  thirty  each  week;  but  this  great  frequency  is  exceptional. 
The  attacks  of  petit  mal  are  much  more  numerous,  but  from  their  very 
transitory  character  it  is  difficult  to  make  any  estimate  which  is  at  all 
useful.  The  irregular  forms  of  the  disease  are  of  greater  interest  as  curi- 
osities than  anything  else,  but  derive  some  importance  from  their  medico- 
legal bearing. 

IRREGULAR   ATTACKS. 

There  may  be  a  form  known  as  aborted  epilepsy,  which  consists  in  the 
expression  of  all  the  features  of  ordinary  haid  mal,  without  complete  loss 
of  consciousness.  The  attacks  may  occur  in  the  course  of  ordinary  epi- 
lepsy. 

The  most  peculiar  examples  of  irregular  seizures  are  described  by  Fal- 
ret,  Hughlings  Jackson,  and  others.  While  in  certain  states  the  patient 
will  do  the  most  eccentric  things  imaginable,  the  mind  being  apparently 
in  a  condition  of  vacuity,  and  the  individual  becomes  more  an  automaton 
than  a  human  being. 

^  JNIesnet,  of  the  St.  Antoine  Hospital,  came  across  a  very  interesting 
case.  The  patient  has  been  known  as  the  "  Automatic  Man,"  and  his 
history  is  as  follows  : — 

"  A  young  man  during  the  late  war  had  a  portion  of  the  left  parietal 
bone,  about  eight  centimetres  in  extent,  carried  away  by  a  ball.  Hemi- 
plegia of  the  right  side  was  the  consequence,  but  this  gradually  disap- 
peared. For  some  time  past  he  has  been  the  subject  of  attacks,  lasting 
from  twenty-four  to  forty-eight  hours,  attended  by  very  extraordinary 
phenomena.  During  these  he  seems  to  act  exactly  like  an  automaton, 
walking  continuously,  incessantly  moving  his  jaw,  knitting  his  brow,  and 

1  Gazette  Hebdomadaire,  July  17,  1874. 


EPILEPSY.  391 

appearing  absolutely  insensible  to  all  that  surrounds  him.  i^ot  uttering 
a  word,  he  walks  straight  forward,  and  when  he  meets  with  an  obstacle, 
stops  short,  explores  it  with  his  hand,  and  tries  to  pass  on  one  side  of  it. 
Surrounded  by  a  circle  of  persons,  he  stops  at  each,  and  endeavors  to  pass 
by  the  intervals  formed  by  their  joined  hands,  then  turns  back,  comes  in 
contact  with  the  next  person,  and  resumes  his  round.  All  this  time  he 
never  manifests  the  slightest  consciousness,  just  as  if  he  were  in  a  state  of 
somnambulism.  He  is  absolutely  insensible  to  pain,  so  that  pins  may  be 
thrust  through  the  cheek  or  into  the  fingers,  or  very  powerful  electric 
shocks  may  be  administered  without  the  slightest  sensibility  being  mani- 
fested. What,  however,  is  very  remarkable,  is  that  by  bringing  him  in 
relation  with  certain  objects  we  are  enabled  to  determine  in  him  the  entire 
series  of  acts  which  are  correlative  with  the  sensation  thus  aroused.  Thus, 
if  a  pen  be  placed  in  his  hand,  he  seeks  for  ink  and  paper,  and  writes  a 
letter  in  a  very  good  hand,  in  which  he  speaks  very  sensibly  about  differ- 
ent matters  which  concern  him.  If  a  leaf  of  cigarette  paper  is  placed  in 
his  hand,  he  feels  in  his  pocket  for  the  tobacco,  rolls  up  the  cigarette  very 
adroitly,  ard,  having  found  his  match-box,  lights  it.  If  the  match  be  ex- 
tinguished just  as  it  reaches  the  cigarette,  he  finds  another,  and  that 
several  times,  until  he  is  allowed  to  light  his  cigarette.  If  at  the  moment 
when  the  match  is  extinguished,  another  already  lighted  is  presented  to 
him  in  its  place,  it  is  impossible  to  induce  him  to  light  the  cigarette  by 
means  of  the  substituted  match.  He  allows  his  moustaches  to  become 
burned  without  offering  any  resistance,  but  he  will  not  employ  the  light 
thus  presented  to  him.  If  chopped  charpie  be  placed  in  his  pocket  in- 
stead of  his  tobacco,  he  makes  the  cigarette  with  this,  and  lights  and 
smokes  it  without  seeming  to  pay  any  attention  to  what  he  is  smoking. 

Among  the  various  experiments  devised  by  Dr.  Mesnet,  there  is  one 
which  is  particularly  curious.  The  young  man  is  a  singer  at  concerts  by 
profession,  and  if  gloves  be  placed  in  his  hands  he  immediately  puts  them 
on,  and  searches  for  paper.  When  a  roll  of  this,  resembling  music  in  form, 
is  given  to  him,  he  places  himself  in  the  proper  position  and  begins  to  sing. 
It  would  seem,  in  fact,  that  tactile  sensation  induced  in  him  becomes  the 
point  of  departui'e,  and  as  if  of  escape,  of  a  series  of  acts  correlative  to  this 
initial  sensation — acts  which  he  accomplishes  automatically,  without 
letting  them  deviate  from  their  habitual  and  regular  succession.  Lastly, 
it  is  to  be  noted  that,  while  in  this  singular  condition,  the  patient  steals  all 
that  comes  within  his  grasp.  If  he  touches  any  person,  he  feels  for  his 
watch-pocket,  and  invariably  detaches  the  watch  and  puts  it  in  his  own 
pocket,  whence  it  may  be  immediately  removed  without  his  making  the 
slightest  opposition.  The  crisis  once  over,  he  has  no  recollection  what- 
ever of  what  he  has  been  doing,  and  becomes  again  perfectly  reason- 
able."^ 

Equally  curious  cases  are  reported  by  Jackson  of  individuals  who 
do  purposeless  things  knoAving  nothing  about  them  afterward.  A  pa- 
tient of  my  own  upon  several  occasions  in  a  condition  akin  to  "  brown 
study,"  walked  from  the  ferry-boat  into  the  wrong  car  and  rode  some 
miles  before  he  discovered  his  mistake.  Many  of  the  curious  cases  of 
absent-mindedness  reported  by  various  authors  were  undoubtedly  irregu- 
lar forms  of  epilepsy. 

1  Med.  Times  and  Gazette,  July  25, 1874. 


392  BULBAR    DISEASES. 

» 

An  irregular  form  of  the  disease  is  known  as  "  masked  epilepsy."  The 
patient  in  this  state  may  not  fall  to  the  ground,  but  while  in  a  state  of 
unconsciousness  will  evince  a  great  deal  of  muscular  activity.  An 
epileptic  in  ray  ward  is  in  the  habit  of  tearing  through  the  hall,  col- 
liding with  such  patients  as  may  happen  to  be  in  her  way,  and  finally 
recovering  consciousness,  when  she  has  no  recollection  of  her  attack.  I 
have  noticed  the  same  phenomena  in  other  cases. 

Another  form  is  connected  with  the  commission  of  purposeless  acts  such 
as  I  have  cited.  Cases  of  persons  who  have  disappeared  and  travelled  about 
the  country  for  some  days,  and  when  found  could  not  give  the  slightest 
history  of  their  whereabouts  are  reported  by  various  authorities.  Snch 
individuals  in  reality,  lead  a  double  life,  and  while  the  automatic  state  pre- 
vails they  may  commit  deeds  of  violence  which  may  subsequently  cause 
a  great  deal  of  trouble ;  and  in  such  cases  only,  the  history  of  undoubted 
epilepsy  should  alone  be  sufficient  to  exonerate  them.  I  believe  it  is 
strongly  improbable  that  there  is  ever  an  attack  of  masked  or  aborted 
epilepsy  without  expression  of  some  of  the  evidences  of  the  true  par- 
oxysm. 

The  sequences  of  epilepsy  are  various,  but  it  does  not  necessarily  follow 
that  any  mental  impairment  should  result.  It  is  true  that  in  some  cases 
such  a  termination  is  possible.  Idiocy  and  epilepsy  sometimes  go  together, 
but  it  must  be  remembered  that  the  former  is  a  congenital  state.  Ex- 
amples of  general  mental  failure  are  by  no  means  rare,  and  in  some  cases 
the  disease  slowly  undermines  the  patient's  intellectual  condition.  "  An 
apathetic  state  is  the  primary  result.  Any  one  who  has  seen  one  of  these 
old  cases  (especially  if  the  patient  be  the  victim  of  petit  mat),  with  dull 
fishy  expression  of  eyes,  dilatation  of  pupils,  a  leaden,  sallow  counte- 
nance, a  full  lip  with  imperfectly  defined  vermillion  border,  sluggish  cu- 
taneous circulation,  loss  of  memory,  and  dulness  of  wits,  will  recognize 
the  condition  I  have  endeavored  to  describe.  Dr.  Gray,^  of  Brooklyn, 
has  directed  attention  to  what  he  believes  to  be  a  certain  test  of  the  epi- 
leptic state.  He  finds  that  the  pupils  of  epileptics  respond  much  more 
actively  to  the  stimulus  of  light  than  in  the  normal  individual.  I  cannot 
say  that  I  have  been  struck  with  this  condition  Dr.  Gill,  the  Resident 
Physician  of  the  Hospital  for  Epileptics  or  Paralytics,  made  an  examina- 
tion of  the  eyes  of  twenty-seven  epileptics.  Of  this  number,  there  was 
ready  response  in  eighteen  cases  ;  of  the  remainder,  seven  responded 
slowly.  In  one  other  case  the  pupils  were  dilated,  and  responded  only 
when  a  bright  light  was  brought  directly  upon  pupil.  In  the  remaining 
case  the  pupils  were  contracted,  and  responded  with  great  difficulty. 
Of  fifteen  cases,  most  of  which  were  of  recent  date,  the  pupillary  response 
was  not  remarkably  rapid.  The  first  eighteen  cases  were  of  long  stand- 
ing. In  nearly  all  of  these  cases  there  was  dilatation  to  a  great  extent 
under  ordinary  circumstances,  and  I  attach  much  more  importance  to  this 
appearance.     When  it  is  borne  in  mind  that  at  best  epilepsy  is  often  a 

Am.  Jour,  of  Med.  Science,  1880. 


EPILEPSY. 

symptomatic  condition  of  various  organic  troubles  whicli  may  affect  the 
eyes  in  different  ways  it  is  difficult  to  attach  pathognomonic  importance 
to  ocular  tests. 

An  epileptic  convulsion  in  infancy  may  give  rise  to  cerebral  hemor- 
rhage from  a  vessel  ruptured  during  the  paroxysm,  but  the  accident  is  al- 
most unheard  of  in  adult  life. 

Epileptic  mania,  which  Reynolds  considers  to  occur  in  about  one-tenth 
of  all  the  cases,  is  not  confined  to  any  particular  time.  It  may  occur  be- 
fore the  attacks,  or,  as  is  more  often  the  case,  succeed  them.  In  this  con- 
dition ei^ileptics  may  be  occasionally  very  dangerous,  and  give  way  to 
outbursts  of  violence,  for  which,  of  course,  they  are  entirely  irresponsible. 

A  man  who  was  a  patient  in  the  out-door  department  of  the  N.  Y.  State 
Hospital  for  Diseases  of  the  Nervous  System,  and  who  had  been 
treated  by  Dr.  J.  J.  Mason,  for  epilepsy  for  a  long  time,  was  subse- 
quently discharged,  as  it  was  supposed,  cured.  A  month  or  two  after- 
wards, having  an  attack  which  was  undoubtedly  epileptic  mania,  he  pur- 
sued his  wife  through  the  streets,  and,  drawing  a  pistol,  shot  her  thi'ough 
the  heart.  After  the  deed  he  expressed  great  remorse,  and  gave  himself 
up  to  the  authorities,  but,  notwithstanding  the  medical  testimony,  was 
sentenced  to  the  State's  prison  for  life. 

Causes. — Of  one  hundred  and  eighty-three  cases  of  epilepsy  I  have 
seen  at  various  times,  the  ages  at  which  the  disease  appeared  were  as  fol- 
lows : — 

Male.  Fermle.  Total. 

Under  10  years 16             ]0  2G 

Between  lb  and  20  years 23            48  71 

Between  20  and  30     "        14  41 

Between  30  and  50     " 29             11  40 

Over  50                        "        4^             1  5 

99  84  183 

Hugon-  has  recently  made  a  valuable  addition  to  the  literature  of  epi- 
lepsy in  an  excellent  brochure  upon  the  subject  of  etiology. 

He  gives  a  table  prepared  by  Martinet  to  show  the  proportion  of  cases 
beginning  between  the  10th  and  20th  years. 

Of  307  cases  collected  by  Musset,  there  were 107 

"     68  "  "  Herpin,         "           27 

"     83  "  "  Maisonneuve,  there  were 46 

"  306  "  "  Alegre,                        "           105 

'•  106  "  "  Leiiret,                       "           42 

"  230  "  "  Morean,                    "          76 

"     43  "  "  Dunaut,                      "          26 

"     70  "  "  Delasiauve,               "           17 

"     75  "  "  Dussart,                     "          40 


^  In  two  of  these  cases  there  was  an  indication  of  syphilis. 
^  Eecherches  snr  les  Causes  de  I'Epilepsie,  etc.,  Paris,  1876. 


394  BULBAR    DISEASES. 

It  will  therefore  be  seen  that  nearly  half  of  all  the  cases  begin  before  the 
twentieth  year.  Beau  collected  273  cases,  43  of  which  began  between  the 
6th  and  12th  years;  49  between  the  12th  and  16th  years;  and  17  be- 
tween the  16th  and  20th  years. 

The  attacks  of  early  life  are  exceedingly  irregular,  and  may  begin  as 
poorly  developed  paroxysms,  which  are  by  many  classified  under  that 
most  convenient  terra  eclampsia,  which  oftentimes  means  nothing.  A 
number  of  these  attacks  of  an  undefined  type  usually  precede  the  genuine 
explosion  of  the  real  disease. 

In  regard  to  sex,  it  may  be  said  that  Beaumes,  Esquirol,  and  Moreau 
were  of  the  opinion  that  the  disease  was  more  confined  to  women  than 
men  ;  but  on  the  other  hand  Celsus,  Joseph  Frank,  Leuret,  and  Sandras, 
as  well  »s  Reynolds  and  others,  take  the  opposite  ground.  From  the 
number  of  cases  I  have  collected  and  tabulated,  I  am  inclined  to  adopt 
the  same  view  as  the  latter. 

Ot'  Hugon's^  cases,  32  in  number,  25  were  men,  and  7  women. 

Professions  seem  to  have  very  little  to  do  with  the  production  of  the 
disease,  if  we  except  bar-tenders  and  liquor-dealers. 

In  regard  to  the  predisposing  influences  of  temperament,  climate,  and 
season,  it  has  been  shown  by  Foville,  Marce,  Falret,  and  Delasiauve,  that 
the  nervous  and  sanguine  temperaments  predispose  to  the  development  of 
the  disease.  Maisonncuve  found  that  of  65  cases,  25  were  of  a  sanguine 
and  2U  of  a  nervous  temperament.  Moreau  considers  that  epilepsy  is 
more  frequent  in  winter  than  in  summer,  while  others  take  the  opj)osite 
view.  Whether  climate  affects  the  development  of  epilepsy,  I  am  unable 
to  say  ;  but,  after  very  carefully  conducted  experiments  in  regard  to  the 
influence  of  temperature,  I  am  prepared  to  state  most  decidedly  that  the 
attacks  are  much  more  frequent  whenever  there  is  a  sudden  change  of 
weather. 

A  writer  in  the  Bevista-Sperimentale,  of  May  or  August,  1875,  has 
given  tables  showing  the  influence  of  atmospheric  changes,  temperature, 
etc.,  upon  the  occurrence  of  attacks.  Before  that  time  I  began  a  series  of 
observations  at  the  Epileptic  Hospital.  These,  when  compared  with  the 
accurately  taken  charts  of  temperature,  barometric  pressure,  wind,  etc., 
of  the  Health  Department,  conclusively  prove  the  truth  of  the  as!:ertion  I 
have  just  made.  The  number  of  attacks  seemed  to  increase  just  at  the 
change ;  and  a  very  hot  day,  followed  by  a  cool  one,  would  show  an  in- 
crease of  from  ten  to  fifteen  seizures  among  my  patients  during  the  cool 
day,  and  vice  versa. 

The  influence  of  heredity  is  more  strongly  shown  in  epilepsy  than  in 
any  other  nervous  disease,  except  it  may  perhaps  be  progressive  muscular 
atrophy.  In  cases  that  I  have  seen  the  taint  can  be  traced  back  for  several 
generations  either  by  epilepsy,  neuralgia,  insanity,  or  other  nervous  di.s- 
eases.  In  one  case  the  maternal  grandfiither  died  insane,  the  paternal 
grandfather  died  of  apoplexy,  the  mother  was  living  though  subject  to 

^  Op.  cit.,  page  7. 


EPILEPSY. 


S95 


neuralgia,  one  brother  had  chorea,  and  the  other  had  committed  suicide 
in  a  fit  of  temporary  insanity.  Other  examples  are  very  much  like  this. 
Leuret^  found  among  126  epileptic  cases  that  there  was  a  history  of  he- 
reditary epilepsy  in  seven  cases.  Beau's  ^  experience  was  equally  interest- 
ing. Of  273  epileptics,  thore  Avas  hereditary  predisposition  in  18  cases. 
Leech  and  Fox^  fixed  the  proportion  of  epileptics  in  whom  hereditary 
taint  was  found  at  36.8  per  cent.,  which,  as  far  as  I  can  judge,  is  no  exag- 
geration. Reynolds*  states  that  in  the  upper  classes  this  hereditary  pre- 
disposition exists  to  a  much  greater  extent,  but  calls  attention  to  the  dif- 
ficulty of  obtaining  information.  I  have  often  been  disappointed  in  get- 
ting reliable  information,  for  this  "  skeleton  in  the  closet "  is  kept  closely 
guarded.  I  have  been  repeatedly  astonished  to  find  how  strong  this  ele- 
ment is  in  the  higher  walks  of  life.  In  one  family  I  find  a  long  succes- 
sion of  insane  ancestors,  idiot  children,  and  dissolute  progeny,  which  fully 
accounted  for  the  transmission  of  the  disease.  It  is  a  fact,  however,  that 
it  does  not  follow  that,  because  a  parent  has  been  epileptic,  the  offspring 
shall  inherit  the  disease.  Voisin  found  among  96  cases,  24  which  fol- 
lowed hereditary  alcoholism  and  phthisis.  It  is  often  due  in  the  first  in- 
stance to  exciting  causes,  which,  if  removed,  would  probably  be  followed 
by  disappearance  of  the  disease. 

As  to  exciting  causes,  I  may  enumerate  bad  habits,  excessive  venery, 
syphilis,  and  uterine  disease,  which  last  I  believe  to  be  one  of  the  mod 
important  of  all  causes  in  the  epilepsy  of  ivomen.  Fright,  grief,  anxiety, 
overwork,  blows  on  the  head,  and  other  traumatisms,  also  enter  extremely 
into  the  etiology  of  the  disease ;  and  the  disorders  of  digestion  and  the 
exanthematous  disease  often  play  a  part  in  its  causation.  Onanism  is  a 
very  common  cause  ;  and  of  24  male  cases  I  have  seen  during  the  past 
year,  this  vice  existed  in  9.  I  may  extract  the  following  data  from  a  paper 
in  which  I  analyzed  the  chronic  cases  under  treatment  at  the  Hospital 
ujDon  Blackwell's  Island  : — 

One-third  of  these  patients  suflfered  from  intercurrent  diseases ; 
two  had  advanced  phthisis ;  several  had  nephritic  disease ;  and  a 
great  many  were  anaemic.  In  regard  to  the  complicating  troubles,  I 
find  that  twelve  were  subject  to  headache,  two  were  hemiplegic  (right), 
the  epilepsy  following  the  hemiplegia,  two  suffdred  from  sclerosis 
(one  locomotor  ataxia,  the  other  diff'used  cerebral  sclerosis),  and  one  was 
an  idiot. 

When  we  came  to  examine  into  the  causes  we  found  more  difficulty 
than  we  anticipated.  The  intelligence  and  memory  were  much  below  par 
in  all.  Scarlatina  and  variola  preceded  the  disease  in  two,  syphilis  in  one. 
In  nine  the  attacks  were  connected  with  menstrual  irregularities  and  ute- 
rine disease  (versions  and  flexions),  two  of  these  were  masturbators  (by 

1  Eecherches,  sur  I'Epileppie,  Arch.  Gen.  de  M6d.,  1843. 

2  Archives  Gen.  de  M^d.,  May,  1836. 

^  Manchester  Medical  and  Surgical  Keporter,  quoted  by  Reynolds. 
*  Syst.  of  Med.,  vol.  ii.,  p.  295. 


396  BULBAR    DISEASES. 

confessiou),  one  of  whom  has  been  cured  since  the  habit  was  broken.  One 
case  only  was  traumatic,  four  were  congenital,  and  several  gave  absurd 
answers  which  were  unsatisfactory.  These  are  examples  of  chronic  cases, 
and  of  course  many  are  intractable. 

Morbid  Anatomy  and  Pathology. — The  variety  of  morbid 
appearances  that  have  been  found  from  time  to  time  give  no  satisfactory 
explanation  of  the  pathology  of  this  disease,  and  we  will  not  enter  exten- 
sively into  their  discussion.  Spicula  of  bone  growing  into  the  brain-sub- 
stance, thickened  meninges,  deformities,  or  depressions  of  the  cranial 
bones,  vascular  anomalies,  cysts,  tuberculous  deposits,  softening,  and  a 
host  of  other  changes  have  been  observed.  Some  of  these  are  important 
appearances  which  should  not  be  dismissed  too  hurriedly.  Undoubtedly 
the  OJ-seous  changes  are  quite  satisfactory  causes.  In  three  cases  I  found 
spiculre  or  nodules  of  bone  growing  into  or  pressing  upon  the  cerebrum. 
In  one  of  these  the  exostosis  had  attained  a  length  of  one  inch,  and  varied 
from  one-eighth  to  one-quarter  of  an  inch  in  diameter.  In  other  cases  I 
have  seen  decided  depressions  of  the  parietal  bones,  which  impinged  to  a 
great  extent  upon  the  brain-substance  beneath.  As  far  as  the  deep  lesions 
go,  nothing  very  conclusive  has  been  found.  Vau-der-Kolk  has  dwelt 
at  length  upon  the  increased  vascularity  of  the  medulla  a-jd  the  softened 
patches  sometimes  present,  but  these  changes  are  just  as  likely  to  be  the 
results  of  the  disease  as  they  are  to  be  the  lesion  which  produces  the  con- 
vulsion. 

It  seems  likely,  however,  that  the  investigations  of  Cazauvieilh  and 
Bouchet,  Bourneville,  Charcot,  and  Delasiauve  in  France,  as  well  as 
those  of  Meyuert  iu  Germany,  must  throw  some  light  upon  the  pathology 
of  this  puzzling  disease.  All  of  these  observers  found  distinct  induration 
of  the  coruu  aramonis,  or  pes  hippocampi.  Cazauvieilh^  reports  eighteen 
autopsies  made  at  La  Salpetriere.  In  nine  of  these  one  or  both  of  the 
cornua  ammonis  were  indurated,  and  at  the  same  time  there  was  indu- 
ration of  the  white  matter  of  the  hemispheres.  Bouchet,^  in  forty-three 
cases,  found  the  same  condition  of  affairs.  He  says, "  La  corne  d'ammon 
est  la  partie  cerebrale  qui  a  le  plus  frequemment  presente  I'induration. 
Cette  alteration  a  souvent  ete  si  frappante,  et  quelquefois  si  coustante, 
que  bien  evideute  neuf  fois  de  suite  pour  quelques  medecins  assistants, 
elle  leur  a  donne  la  conviction  qu'elle  representait  exactemeut  la  cause 
pathologique  de  I'epilepsie." 

Bourneville  observed  this  lesion  five  times  out  of  thirty-four  during  the 
years  1866 — 1874.  Meynert  has  repeatedly  discovered  induration  of  this 
part,  and  considers  it  a  pathognomonic  sign.  In  his  examination  the 
cornua  ammonis  were  found  atrophied,  and  appeared  to  be  of  a  cartilagi- 
nous hardness,  and  had  undergone  a  general  alteration. 

Of  ten  autopsies  that  I  have  made,  six  presented  this  lesion,  and  in  one 

1  Archiv.  Gen.  de  MeJ.,  3nie  Anne,  1825,  i.,  ix.,  p.  510,  et  4me  Anne,  1827,  i.,  v., 
p.  5. 

^  Sur  I'Epilepsie  (Annales  Med.  Psychologiques,  1853,  1.  v.,  p.  209). 


EPILEPSY.  397 

I  found  it  to  be  uncomplicated.  The  other  four  cases  presented  nothing 
distinctive.  In  two  the  left  hippocampus  major  was  indurated,  in  three 
both  were  indurated,  and  in  one  the  right  was  the  seat  of  the  same 
change.  In  one  of  these  the  extreme  exterior  part  of  the  pes  hippocam- 
pus was  quite  firm  ;  the  little  crenations  or  irregularities  were  more 
marked  than  in  the  healthy  brain,  as  there  had  evidently  been  some 
atrophy  with  contraction.  In  one  the  gray  matter  just  adjacent  to  the 
hippocampus  major  contained  several  indurated  patches.  In  two  cases 
the  veins  which  skirt  the  inner  edge  of  the  corpora  striata  at  the  line  of 
the  velum  interpositum,  and  receive  branches  from  these  bodies,  were 
quite  distended  with  blood,  as  were  the  ven^e  galeni.  The  white  matter 
in  both  anterior  lobes  was  quite  hard  in  three  cases.  In  one  case  there 
were  minute  extravasations  throughout  the  brain  and  in  the  medulla. 
In  two  cases  there  was  effusion  into  the  lateral  ventricles.  The  cranial 
bones  in  one  case  were  found  to  be  considerably  thickened.  In  all  of  the 
cases  there  were  evidences  of  great  meningeal  hypersemia.  In  three  of 
these  cases  I  found  microscopical  disorganization  of  a  granular  charac- 
ter of  the  nerve-elements  in  the  medulla.  The  vascular  walls  were  thick- 
ened, and  at  certain  points  ruptured,  the  places  of  rupture  having  no 
special  pathological  relation  as  far  as  the  nuclear  involvement  was  con- 
cerned. 

In  three  cases  which  are  not  included  in  the  ten  referred  to,  I  found 
osseous  growths.  Although  this  lesion  of  the  cornua  ammonis  very  rarely 
exists  alone,  it  seems  to  be  quite  a  constant  morbid  appearance,  and  it 
now  remains  for  us  to  discover  whether  the  condition  is  peculiar  to 
epilepsy. 

Pfluger^  has  made  300  autopsies  at  the  Asylum  of  Ybbs,  and  in  25 
cases  of  epilepsy,  sclerosis  of  the  cornua  ammonis  was  found.  The  entire 
number  of  epileptics  was  43.  The  cases  in  which  their  appearance  was 
found  to  be  most  perfectly  shown  were  those  which  dated  from  infancy. 
In  three  cases  the  disease  did  not  begin  until  after  twenty.  Of  twenty- 
three  in  whom  the  attacks  were  frequent  and  violent,  seventeen  presented 
this  lesion.  He  supposes  the  alteration  to  be  due  to  malnutrition  fol- 
lowing vascular  trouble. 

Epilepsy  is,  without  doubt,  an  organic  affection,  the  established  disease 
beginning,  perhaps,  after  a  peripheral  irritation  has  been  transmitted  re- 
peatedly to  the  centres  ;  but  after  the  disease  is  fairly  developed,  the  con- 
vulsions are  not  necessarily  produced  by  the  excitement  of  such  distal 
irritation  ;  for,  as  Nothnagel  shows,  in  cases  dependent  upon  a  cicatrix 
the  attacks  are  not,  as  a  rule,  excited  only  by  irritation  of  the  cic  trix. 
The  clinical  features  of  the  disease  prove  the  truth  of  this  rule ;  for,  in 
any  well-established  case,  gastric,  uterine,  or  any  other  reflected  irrita- 
tion may  give  rise  to  the  seizures,  or  they  may  take  place  in  an  apparently 
spontaneous  manner.     We  must,  therefore,  consider  that  epilepsy  is  a 

■    Allegera.  Zeitsclirift  filer  P.-ych.  and   Eevue  des.  Science.^  Med.,  33,  1381,  xxvi. 
p.  359. 


S98  BULBAR     DISEASES. 

disease  of  an  organic  character,  expressing  itself  after  either  some  distal 
or  central  stimulation  iu  aa  irregular  manner,  or  the  result  of  both. 
That  it  is  connected  with  central  changes  there  is  no  reason  to  doubt ; 
though  these  changes  are  by  no  means  uniform. 

The  experiments  of  Brown-Sequsrd  have  thrown  much  light  upon  its 
pathology,  though  Xothnagel  and  others  do  not  unreservedly  accept  his 
views. 

The  experiments  of  Brown-Sequard  were  chiefly  made  upon  guinea-pigs. 
He  produced  epilepsy  by  division  of  the  trunk  of  the  sciatic,  internal  pop- 
liteal and  posterior  roots  of  the  nerves  inner  seating  the  lower  extremities, 
and  by  injury  of  various  parts  of  the  brain,  the  corpora  quadrigemina, 
and  cerebral  peduncles.  He  also  divided  the  cord  at  different  points 
partially  or  completely,  and  shows  that  injury  of  the  lower  part  of  the  cord 
seemed  to  have  more  to  do  with  the  subsequent  epilepsy  than  when  the 
upper  part  was  mutilated.  After  these  experiments,  the  first  appearance 
of  epilepsy  occurred  in  from  four  to  six  weeks.  The  attacks  were  either 
spontaneous,  or  followed  irritation  of  certain  parts  of  the  skin  which 
were  included  in  the  so-called  "  epileptic  or  epileptigenous  zone."  This 
included  the  cheek,  anterior  part  and  side  of  the  neck,  and  a  portion  of 
the  back.  This  region  became  ante-thetic,  and  the  hair  usually  fell  out. 
Any  irritation  of  this  tract,  such,  for  instance,  as  pinching,  gave  rise  to 
an  attack.  Ultimately  the  antesthesia  diminished,  and  the  attacks  sub- 
sided, so  that  it  was  impossible  to  excite  them.  The  "  epileptic  zone  " 
corresponded  to  the  side  upon  which  the  nerve  or  cord  injury  had  taken 
place. 

Other  forms  of  experimentation  have  produced  convulsive  attacks,  or  a 
condition  resembling  epilepsy.  These  were  blows  upon  the  back  of  the 
head  (Westphall) ;  irritation  of  the  cortex-cerebri  (Hitzig)  ;  ligation  of 
the  carotids  and  vertebral  arteries  (Cooper,  Hall,  Kussmaul,  and  Tenner)  ; 
irritation  of  the  peripheral  sensory  nerves  (Nothnagel,  Krauspe).  The 
labors  of  these,  as  well  as  others,  indubitably  show  that  the  epileptic  attack 
is  connected  with  cerebral  auremia,and  the  experimental  production  of  this 
vascular  state  when  irritation  of  peripheral  sensory  nerves  has  been  made 
furnishes  another  link  in  the  chain. 

The  question  of  localization  next  arises.  Brown-Sequard,  Schiff,  Rey. 
nolds,  and  Kussmaul  and  Tenner  have  all  demonstrated  that  the  medulla 
oblongata  is  the  probable  pathological  seat  of  the  disease.  It  has  been 
proved  by  them  thata  so-called  "convulsive  centre"  is  here  located,  which, 
when  excited,  by  reflex  stimuli,  gives  rise  to  extensive  spasms  of  both  kinds 
of  the  voluntary  muscles  ;  that  whether  the  irritation  comes  ex  chorda  or 
ex  cerebro,  there  is  primary  bulbar  congestion,  a  cerebral  anaemia,  and  a 
secondary  cerebral  congestion  ;  that  such  congestion  follows  reflex  spasm 
of  the  cervical  muscles,  and  that  a  condition  of  venous  engorgement  en- 
sues from  pressure  upon  the  large  vessels  of  the  neck.  The  pathology  of 
the  confirmed  disease,  as  it  has  been  generally  considered  heretofore,  may 
be  brieflv  stated  as — 


EPILEPSY.  399 

A.  The  existence  of  a  condition  of  reflex  excitability  of  the  medulla 
from  a  long-standing  reflected  irritation. 

B.  An  exciting  impression  transmitted  from  the  periphery,  or  from  a 
central  part. 

C.  The  irritation  of  the  vaso-raotor  centre  (described  by  Dittraar  and 
others)  through  congestion  at  the  floor  of  the  fourth  ventricle. 

D.  A  secondary  ansernia  and  hyperreraia  of  the  hemispheres. 
The  production  of  symptoms  probably  due  to — 

1.  a.  Ansernia  of  the  brain  ;  6.  Consequential  primary  loss  of  conscious- 
ness, etc. 

2.  Irritation  of  "  convulsive  centre,"  with  tonic  muscular  contrac- 
tion. 

3.  a.  Irritation  of  nuclei  of  lower  cranial  nerves ;  h.  Consequential 
asphyxia.  Contraction  of  muscles  of  neck,  pressure  upon  vessels,  etc., 
secondary  stupor,  clonic  convulsions. 

Van-der-Kolk^  explains  the  tongue-biting  as  the  result  of  irritation  of 
the  nuclei  of  the  hypoglossal  nerves. 

The  observations  of  Hughlings  Jackson"  and  other  modern  observers 
throw  much  light  upon  the  pathology,  and  give  it  a  new  and  broader  as- 
pect. The  former  proves  "that  those  parts  are  wont  to  suffer  first 
and  most  which  serve  in  the  voluntary  (special)  operations,  aad  those  last 
and  least  which  serve  in  the  more  autouiatic  (general  operations)." 

Briefly  to  illustrate  this,  he  quotes  from  an  article  ia  the  Lancet 
demonstrating  that  the  three  points  at  which  the  convulsions  often  begin 
are  :  "(1)  in  the  hand  ;  (2)  in  the  face,  in  the  tongue,  or  both  ;  (3)  in  the 
foot." 

This  confirms  the  idea  that  the  onset  begins  in  the  parts  devoted  more 
particularly  to  the  execution  of  voluntary  movements.  He  has  been 
enabled  to  prove  that  in  this  manner  the  parts  first  attacked  are  those 
which  are  more  commonly  afiected  in  hemiplegia.  He  also  calls  attention 
to  the  phenomenon  of  aphasia,  with  epilepsy  beginning  in  the  right  cheek. 

"  Epilepsies,"  he  says,  "  are  the  results  of  the  second  class  of  functional 
changes ;  they  are,  speaking  briefly,  discharging  lesions.  But  there  are 
many  varieties  of  discharges.  Defined  from  the  paroxysm,  an  epilepsy 
is  a  sudden,  excessive,  and  rapid  discharge  of  gray  matter  of  some  part 
of  the  brain  ;  it  is  a  local  discharge.  To  define  it  from  the  functional 
alteration,  we  say  there  is  in  a  case  of  epilepsy,  gray  matter  which  is  so 
abnormally  nourished  that  it  occasionally  reaches  very  high  tension  and. 
very  unstable  equilibrium,  and,  therefore,  occasionally  explodes.  .  .  . 
It  will  be  observed  that  the  discharging  lesion  of  epilepsy  is  supposed  to 
be  a,  j^ermanent  lesion  ;  there  is  gray  matter  which,  since  it  is  permanently 
under  conditions  of  abnormal  nutrition,  is  permanently  abnormal  in 
function.  That  this  permanent  abnormality  is  a  varying  state,  has  been 
said  ;  it  has  been  remarked  that  the  gray  matter  occasionally  reaches 

^  Brain  and  Spinal  Cord,  Sydenham  Trans. 
^  W.  Ridiog  Reports,  vol.  iii.  p.  315,  et  seq. 


409  BULBAR    DISEASES. 

high  tension,  and,  therefore,  occasionalhj  discharges  (or  is  discharged). 
There  are  waves  of  stability  and  instability.  It  follows  from  this 
that  the  first  fit  is  supposed  to  be  a  discharge  of  a  part  which  has  for 
some  time  before  been  in  a  state  of  malnutrition  ;  and  a  still  further 
inference  is  that  such  '  causes  '  of  epilepsies  as  fright  are  only  determin- 
ing causes  of  the  first  explosion.  Many  of  the  premonitory  symptoms  of 
a  first  attack  are  probably  results  of  slight  discharges  ;  they  are  minia- 
ture fits.' 

That  irritation  of  the  auditory  apparatus  may  give  rise  to  a  variety  of 
epilepsy  there  can  be  no  doubt,  but  such  cases  I  believe  to  be  rare, 
Browu-Sequard^  states  that  Mr.  Hinton,  an  English  surgeon,  has  reported 
several  where,  after  deaih,  no  lesion  was  discovered,  except  evidences  of 
disease  of  the  middle  ear.  My  friend  Dr.  Roosa  tells  me  that  out  of  five 
or  six  thousand  cases  of  aural  disease  he  has  seen,  he  does  not  remember 
but  one  of  this  kind  : — This  patient  was  under  my  observation. 

John  W.  P ,  aged  15  years  and  6  months,  a  stout  and  apparently 

healthy  boy,  well  nourished,  and  presenting  7io  external  evidences  of  dis- 
ease;  family  history  good.  His  mother  stated  that  he  had  always  been 
a  rather  dull  boy,  and  that  at  school  he  was  generally  behind  in  his  stu- 
dies, and  did  not  seem  to  learn  easily,  and  when  sent  on  errands,  he  was 
unreliable  and  forgetful.  There  is  no  history  of  injury  or  sudden  fright, 
nor  has  there  been  any  known  predisposing  or  exciting  cause;  but  at  the 
age  of  eight  years  he  had  a  severe  attack  of  scarlatina,  which  left  him 
with  a  remaining  otitis,  most  severe  on  the  right  side,  and  resulting  in  a 
profuse  discharge  of  pus,  which  still  continues  in  a  modified  degree,  but 
is  not  so  excessive  as  it  was  a  month  ago.  About  six  ■weeks  ago  he  began 
to  syringe  his  ears  with  a  carbolic  acid  solution,  which  had  the  eflTect  of 
removing  a  large  mass  of  what  was  probably  inspissated  pus ;  and  his 
hearing,  which  had  before  been  quite  defective,  became  greatly  improved, 
and  he  no  longer  complained  of  various  subjective  noises,  such  a?  buzzing 
and  roaring.  When  the  quantity  of  discharge  was  diminished,  his  ears 
became  painful,  and  pressure  on  the  mastoid  processes  caused  much  suf- 
fering. Ever  since  the  scarlatina  he  has  had  frontal  and  occipital  head- 
ache, which  is  always  constant.  About  a  mouth  ago  he  had  his  first 
epileptiform  attack,  and  this  occuried  about  noon  one  day  when  he  was 
using  his  syringe.  Without  warning,  he  suddenly  fell  to  the  floor,  be- 
came convulsed,  and  in  a  few  minutes  recovered,  and  did  not  fall  asleep; 
but  a  semi-unconscious  state,  however,  supervened. 

The  next  attack  came  on  four  days  after,  at  3  P.  M.  While  he  was 
chatting  with  a  friend,  he  suddenly  stopped  talking,  and  fell.  This 
attack  was  much  more  violent  than  the  first  one.  They  now  become 
more  and  more  frequent,  until  about  two  weeks  ago,  when  on  one  occa- 
sion he  had  fifteen  during  twenty-four  hours.  Siuce  then  he  has  not  had 
so  many,  having  had  between  one  and  five  attacks  every  day  but  one, 
which  was  the  only  day  he  missed  the  attack  since  the  commencement. 
During  some  of  the  attacks  he  is  very  violent,  while  in  others  not  so 
much  so.  His  appetite  has  been  irregular  for  some  time  past.  An  ex- 
amination made  by  Dr.  Baldwin,  House-physician  of  the  Epileptic  and 


^  Central  Nervous  System,  p.  93,  ami  Gaz.  MeJ.  de  Paris,  1842,  p.  2). 


EPILEPSY.  401 

Paralytic  Hospital,  and  myself,  revealed  tenderness  on  pressure  over 
mastoid  processes,  but  mostly  on  the  right  side.  He  has  had  no  definite 
aura,  but  peculiar  sensations  which  he  cannot  describe,  jDreceding  his 
attacks.  He  complains  of  vertigo  and  nausea,  and  muscular  weakness 
after  the  slightest  exertion.  He  invariably  returns  to  consciousness  almost 
immediately  after  the  attack,  attempts  to  rise  and  walk,  but  is  usually 
quite  feeble. 

Examination  of  Ears. — R. :  Discharge  scanty,  thin,  and  sero-purulent ; 
and,  on  examination,  the  membranum  tympani  is  found  absent.  The 
tick  of  a  watch  is  heard  only  when  the  watch  is  pressed  against  the  ear ; 
a  roaring  sound  is  always  present. 

L. :  The  same  examination  shows  more  or  less  congestion  of  the  tym- 
panum, Avith  evident  signs  of  otitis  media ;  but  there  is  not  so  much  joain 
on  this  side,  and  the  hearing  is  better,  the  ticking  of  the  watch  being 
heard  at  three  inches. 

Patient  has  complained  lately  of  deep,  severe  pain  in  the  frontal,  but 
extending  back  to  the  occipital  region.  With  this  pain  there  is  dizziness, 
especially  when  he  stands,  thus  making  it  difficult  for  him  to  preserve 
his  equilibrium,  which  is  strikingly  shown  by  his  irregular  movements. 
When  sitting  up  in  bed,  he  complains  that  objects  move  up  and  down, 
and  not  horizontally,  as  we  should  expect  to  find  in  ordinary  auditory 
vertigo  ;  and  a  very  interesting  and  peculiar  symptom  are  the  movements 
he  makes  to  joreserve  his  relation  with  surrounding  objects,  his  body 
moving  up  and  down,  and  his  head  swaying  strangely.  He  is  very  sus- 
ceptible to  noises  and  bright  lights,  either  being  capable  of  inducing  a 
spasm  at  times.  Vomiting  from  an  empty  stomach  is  occasional,  with 
dilatation  of  pupils.  The  vision  of  right  eye  is  at  times  entirely  lost,  but 
at  others  is  unimpaired.  Muscse  volitantes  are  frequently  complained  of. 
Examination  of  urine  affords  negative  results. 

Observations  during  an  attach  or  convulsion,  which  occurs  at  no  regular 
intervals,  but  is  a  constant  result  of  irritation  of  the  internal  auditory  ajjpa- 
ratus : — 

Ear  syringed  at  9.55  A.  M.  Patient  calm,  and  not  at  all  nervous  ; 
skin  of  normal  hue ;  pulse  regular ;  temperature  normal ;  pupils  some- 
what dilated.  He  passed  a  good  night,  and  suffered  but  little  pain, 
though  his  vertigo  was  still  troublesome.  He  was  placed  upon  a  bed, 
and  the  point  of  an  ordinary  two-ounce  syringe,  filled  with  tepid  water, 
was  inserted  in  the  external  meatus  of  the  right  ear,  and  the  contents 
gradually  expelled.  This  caused  some  pain  and  dizziness,  which  increased 
as  more  water  was  injected  ;  and  when  one  ounce  had  been  thrown  in, 
the  patient  became  suddenly  unconscious,  and  the  head  was  drawn  from 
one  side  to  the  other  by  rapid  clonic  contractions  of  the  muscles  of  the 
neck,  and  almost  at  the  same  time  the  convulsion  became  general,  the 
muscles  of  the  back  being  extensively  involved. 

About  five  seconds  after  this,  there  were  clonic  spasms  of  the  muscles 
of  the  jaw,  so  that  the  patient  snapped  his  teeth,  and,  at  the  same  time, 
forcibly  inspired,  giving  vent  to  a  peculiar  noise  which  might  be  easily 
compared,  by  a  person  of  lively  imagination,  to  the  bark  of  a  dog. 

This  paroxysm  lasted  two  minutes,  and  during  its  continuance  the 
pupils  were  widely  dilated.  The  patient  remained  unconscious ;  but 
there  was  neither  pallor  nor  suffusion  of  the  face.  Thirty  seconds  after- 
wards, a  period  of  muscular  relaxation  succeeded,  a  fresh  attack  followed, 
26 


402  BULBAR    DISEASES. 

during  -which  there  was  more  marked  opisthotonos,  much  more  noise,  but 
no  frothing  at  the  mouth.  Pupils  still  dilated,  though  perhaps  not  so 
much  so  as  at  first,  while  the  skin  was  slightly  suffused  ;  but  there  was 
no  duskiness.  Duration,  one  and  a  half  minute.  Ten  o'clock  and  thirty 
seconds,  after  slight  relaxation  and  subsidence  of  movements,  the  lateral 
jactitation  of  the  head  again  began ;  and  at  ten  o'clock  and  one  minute  a 
violent  accession  of  clonic,  and  afterwards  tonic  spasms  made  their  ap- 
pearance. The  eyeballs  had  throughout  been  uncovered,  and  at  first 
Avere  stationary  and  immovable,  or  almost  so  ;  but  now  they  were  agitated 
by  nystagmatic  movements,  and  the  pupils  were  dilated.  This  paroxysm 
lasted  but  thirty  seconds.  At  ten  o'clock  and  three  minutes  there  was 
another  seizure,  during  which  the  left  sterno-cleido-mastoideus  was  in- 
volved in  a  prolonged  tonic  contraction.  The  pupils  now  partially  re- 
turned to  their  normal  condition,  which  was  one  of  slight  dilatation  ;  and 
at  ten  o' clock  and  four  minutes  the  patient  became  semi-conscious,  answered 
questions  in  monosyllables,  and  after  a  few  minutes  recovered  entirely. 
The  pulse  suffered  no  variation,  except,  perhaps,  after  two  minutes  had 
elapsed  from  the  beginning  of  the  seizure,  when  it  seemed  to  increase  in 
volume,  and  perhaps  slightly  in  rapidity.  There  was  an  entire  absence 
of  any  external  evidence  of  asphyxia,  which  is  so  marked  in  the  more 
familiar  form  of  epilepsy. 

I  have  ascertained  that  the  convulsions  may  be  precipitated  by  simply 
blowing  into  the  external  auditory  meatus. 

Diagnosis. — Epileptic  attacks  may  be  mistaken  for  the  convulsions 
of  Bright's  disease,  infantile  convulsions,  hysteria,  alcoholism,  opium 
poisoning,  syncope,  and  softening,  and  the  disease  is  occasionally  simu- 
lated by  malingerers  and  others.     I  may  briefly  dispose  of  the  above: 

1.  Ursemic  convulsions  are  generally  preceded  by  drowsiness  or  coma, 
delirium  and  stertor.  The  limbs  may  be  oedematous,  and  the  urine  con- 
tain albumen. 

2.  Infantile  convulsions  from  worms,  dentition  and  other  eccentric 
causes,  are  usually  attended  by  a  febrile  condition.  The  convulsions  are 
of  short  duration,  and  are  characterized  by  complete  loss  of  consciousness. 
The  discovery  and  removal  of  the  cause  usually  effect  a  disappearance  of 
the  attacks. 

3.  Hysteria      (See  article  Hystero-Epilepsy.) 

4.  Alcoholism  and  opium  poisoning  are  characterized  by  a  more  pro- 
tracted stage  of  unconsciousness,  and  by  a  contraction  of  the  pujiils  in  the 
latter. 

5.  Fainting  attacks  may  resemble  the  petit-mal,  but  there  are  no 
spasms,  and  the  pulse  is  feeble. 

6.  Softening  and  other  organic  states  give  rise  to  convulsions,  but  the 
accompanying  symptoms  should  enable  the  observev  to  make  the  diagno- 
sis in  every  instance. 

Simulated  convulsions  may  deceive  a  careless  person,  but  the  normal 
condition  of  the  pupil,  and  the  eagerness  of  the  individual  to  play  his 
part  perfectly  which  he  does  not  do,  lead  to  the  detection  of  the  imposi- 
tion ;  and  the  excessive  pallor  of  the  first  stage  can  never  be  simulated. 


EPILEPSY.  403 

^  Dr.  Carlos  Macdonald  reports  the  case  of  a  patient  who  feigned  epilepsy 
and  who  was  known  as  Clegg  the  "  dummy  chucker."  Clegg  was  a 
criminal,  and  feigned  epilepsy  so  successfully  that  he  escaped  hard  work 
and  was  generally  regarded  by  a  number  of  prison  physicians  as  an  ob- 
ject of  sympathy.  He  submitted  to  all  manner  of  painful  tests,  and  upon 
one  occasion  he  actually  fell  twenty  or  thirty  feet  in  one  of  his  shammed 
attacks.  Dr.  Macdonald,  however,  was  suspicious  and  watched  him  very 
carefully  and  finally  compelled  the  man  to  confess.  In  his  pretended 
paroxysm  the  hands  were  closed  but  the  thumbs  were  not  so  closed,  nor 
were  they  flexed  at  any  time,  and  the  sphincters  were  never  relaxed. 
His  facial  expression  at  times  betrayed  him  when  he  was  closely  watched. 
There  was  no  lividity  beneath  his  nails.  These  indications,  together 
■  with  the  patient's  manner,  which  was  ostentatious,  so  far  as  showing  his 
scars  and  alluding  to  his  feelings  was  concerned,  convinced  Dr.  Macdon- 
ald of  the  deception. 

The  syphilitic  form  of  the  disease  resembles  much  the  ordinary  variety, 
but  in  some  instances  it  is  of  the  greatest  importance  to  distinguish  its 
specific  nature,  as  of  course  the  treatment  is  entirely  different  from  that 
employed  in  the  non-specific  disease.  Buzzard,  who  has  given  us  an 
admirable  little  work  on  the  syphilitic  neuroses,  lays  great  stress  upon  the 
necessity  of  recognizing  the  variety  of  pain  as  a  diiferential  symptom. 

"If  pain  in  the  head  be  associited  with  convulsive  attacks,"  he  says, 
"  it  generally  precedes  the  attack  in  syphilitic  convulsions,  and  is  often 

localized  in  one  particular  spot In   simple  epilepsy  (if  it  be 

present)  it  almost  always  follows  the  fit,  is  difl^'used  over  the  forehead,  and 
is  at  no  time  a  strongly  marked  symptom."  The  age  of  the  patient,  and 
the  time  from  which  the  attacks  date,  are  also  of  great  importance  in  this 
connection.  It  is  not  probable  that  syphilitic  epilepsy  would  begin  early 
in  life,  or,  at  least,  before  puberty,  but  simple  epilepsy  dates  from  early 
childhood. 

Prognosis. — The  duration  of  the  disease  has  much  to  do  with  the 
prognosis,  and  the  mode  of  origin,  form  of  expression,  and  complicating 
conditions  must  all  be  considered  before  an  opinion  is  given.  If  the 
disease  be  of  idiopathic  origin,  or  if  it  be  due  to  violence,  i.  e.  injuries  to 
the  head,  the  prognosis  is  bad.  If  it  be  due  to  eccentric  causes  or  syphilis, 
there  is  reason  to  be  hopeful.  Hereditary  predisposition  is  an  obstacle  in 
our  path  which  sometimes  blocks  the  way  to  a  cure.  I  have  found  that 
XhQ  petit-mal  {&  also  less  amenable  to  treatment  than  the  severe  form,  and 
that  it  is  pretty  sure  to  produce  an  impaired  mental  condition. 

Reynolds  thinks  that  the  attacks  which  recur  rapidly  are  more  amena- 
ble than  those  which  take  place  at  long  intervals,  but  this  has  not  been 
my  experience.  If  there  be  any  considerable  congenital  lack  of  intelli- 
gence the  case  may  be  considered  as  incurable.  The  unfavorable  condi- 
tions are  the  occurrence  of  a  great  many  attacks  in  a  short  space  of  time, 
the  biting  of  the  tongue,  and  a  condition  which  has  been  known  as  the 

^American  Journal  of  Insanity,  July,  1880. 


404  BULBAR    DISEASES. 

"status  epilepticus,"  in  which  the  patient  lapses  into  a  comatose  state, 
and  there  are  a  number  of  fi's  in  close  succession.  Death  in  the  actual 
lit  is  not  common,  and  I  know  of  but  six  fatal  cases :  five  from  the  dis- 
ease, and  one  from  falling  upon  a  sharp  iron  point  which  penetrated  the 
orbit. 

Treatment. — Before  entering  upon  the  discussion  of  particular 
modes  of  treatment,  I  desire  again  to  refer  to  certain  etiological  facts 
which  bear  to  a  great  extent  upon  the  selection  of  remedies. 

I  may  be  pardoned  for  calling  attention  to  practical  points  which 
may  appear  unimportant  to  some  ;  but  an  experience  gained  from  the 
management  of  a  great  many  cases  teaches  me  that  they  are  to  be  care- 
fully considered  in  selecting  a  plan  of  treatment.  These  simple  indica- 
tions, I  am  convinced,  are  too  often  overlooked  even  by  painstaking  and 
careful  medical  men.  I  allude  to  the  necessity  for  discovering  the  excit- 
ing cause.  I  am  every  day  made  to  feel  that  the  idiopathic  cases  do  not 
form  so  large  a  proportion  as  they  were  once  thought  to.  AVith  this  be- 
lief I  am  satisfied  that  empiricism  and  routine  management  are  bad 
methods.  Any  one  who  examines  all  his  cases  thoroughly  will  recognize 
the  delicate  shades  in  epilepsy,  variations  which  are  exhibited  in  other 
diseases  presenting  more  pronounced  and  better  defined  symptoms  ;  con- 
sequently there  are  evidences  of  pathological  action,  which  are  not  always 
grouped  alike,  and  therefore  all  cases  are  not  to  be  treated  in  the  same 
manner.  I  ascribe  the  moderate  success  I  have  had  in  the  management 
of  this  disease  to  the  recognition  of  these  difierences. 

Xot  only  may  obstinate  epilepsy  result  from  masturbation,  but  it  may 
be  due  to  many  diseases  of  women,  and  it  is  produced  by  eccentric 
irritations  of  various  kinds,  or  by  centric  irritation,  such  as  maybe  asso- 
ciated with  toxaemia. 

Sir  Charles  Locock  ^  called  attention  to  many  cases  he  had  treated 
where  uterine  irritation  was  the  exciting  cause;  and  I  think  others  have 
had  the  same  experience.  In  one  of  Locock's  cases  the  patient  was 
afiected  particularly  at  the  menstrual  periods. 

Some  of  these  peripheral  causes  are  curious  in  the  extreme.  Through 
the  kindness  of  Dr.  Gibney,  of  New  York,  I  was  enabled  to  see  a  child 
who  had  accidentally  injured  her  ear  with  her  parasol,  the  brass  tip  of 
which  remained  for  some  time  imbedded  in  the  external  auditory  meatus. 
As  a  result,  convulsions  of  an  epileptic  character  were  caused,  and  it  was 
not  until  some  time  afterward  that  the  foreign  body  was  discovered  and 
removed.  In  another  case  I  treated,  the  epilepsy  was  unmistakably  due 
to  a  bad  habit  the  woman  had  of  wearing  a  number  of  heavy  garments 
about  her  hips,  which  produced  some  uterine  change.  When  this  condi- 
tion of  affairs  was  noticed,  and  the  skirts  removed,  she  immediately  re- 
covered. At  the  root  of  many  epilepsies,  as  well  as  other  neuroses,  are 
reflex  causes — the  starting-point  being  the  organs  of  digestion,  or  those 
contained  in  the  pelvis.     Of  course  the  varieties  of  epilepsy  of  an  idio- 

1  Med.  Times  and  Gazette,  May  23,  1853. 


EPILEPSY.  405 

pathic  nature,  or  those  caused  by  traumatism  or  organic  disease,  will  defy 
the  best  efforts  of  the  physicians. 

In  prescribing  for  our  patient  there  are  five  indications  to  observe  : — 

1.  Removal  of  exciting  causes,  if  possible. 

2.  The  diminution  of  exaggerated  reflex  susceptibility  of  the  medulla. 

3.  Equalization  of  cranial  circulation. 

4.  Abortion  of  paroxysms. 

5.  Improvement  of  general  condition. 

For  the  accomplishment  of  these,  it  is  imperative  that  a  judicious  and 
discreet  selection  of  drugs  should  be  made  ;  and  among  those  which  are 
the  most  effective  I  may  mention  : — 

The  Bromides :  sodium,  potassium,  ammonium,  calcium,  lithium,  iroa 
Chloral  hydrate.  Strychnine.  Arsenic. 

Belladonna.  Ergot.  Amyl-nitrite. 

Digitalis.  Mercury.  Tri-nitro-glycerin. 

Cod-liver  oil. 

I  have  not  classified  these  remedies,  as  it  is  unnecessary  to  do  so;  but 
will  now  say  a  word  in  regard  to  their  usefulness. 

No  one  drug  can  be  declared  a  s]3ecific,  as  I  am  sorry  to  see  has  been 
done  ;  and  we  must  not  be  too  eager  to  accept  the  sanguine  results  of 
certain  over-enthusiastic  authorities,  and  be  governed  thereby.  I  allude 
more  especially  to  the  almost  universal  use  of  the  bromides  to  the  exclu- 
sion of  everything  else,  and  also  to  their  employment  in  quantities  which 
often  ruin  the  patients,  or,  at  any  rate,  produce  a  condition  of  diminished 
vitality,  which  is  inconsistent  with  any  hope  of  success.  Radcliffe's^  idea 
in  this  respect  is  a  good  one  :  "  There  is  reason  to  believe  that  the  thera- 
peutics of  convulsion  must  be  based  upon  the  notion  that  vital  power  has 
to  be  reinforced,  and  not  upon  the  contrary  opinion."  What  the  proper 
dose  is  has  not  been  clearly  settled  by  any  one.  There  are  neurologists 
who  believe  in  toxic  doses,  and  there  are  others  who  prescribe  quantities 
which  are  almost  small  enough  to  be  inert.  In  England  it  has  been  the 
custom  to  prefer  the  small  doses.  I  have  seen  the  prescription  of  a 
very  distinguished  general  practitioner,  who  some  years  ago  thought  five 
grains  of  the  bromide  of  potassium  a  sufficient  dose  ;  but  this  has  now 
changed.  Einger^  recommends  from  30  to  60  grains  in  the  day  ;  Rad- 
clifie,-^  45  grains ;  Russell  Reynolds,*  30  to  90  grains ;  Bartholow,"  30 
to  240 

Handfield  Jones''  remarks  that  there  is  a  great  difference  in  the  tole- 
rance of  individuals  in  regard  to  the  bromides — some  persons  not  being 
able  to  stand  five  grains,  while  others  will  not  be  afiected  by  doses  of  less 
than  forty  grains. 

^  Pain,  Epilepsy,  and  Paralysis,  p.  215. 

2  Handbook  of  Therapeutics,  p.  92. 

"  Op.  cit.,  p.  202. 

*  Op.  cit.,  p.  323,  vol.  ii. 

5  Materia  Medica  and  Therapeutics,  p.  371. 

fi  Functional  jS^ervous  Diseases,  p.  325. 


406  BULBAR   DISEASES. 

My  own  experience  has  taught  me  that  the  best  effect  can  be  gained  by 
the  repeated  administration  of  sixty  grains  in  the  twenty-four  hours. 
The  larger  doses  produce  rapid  bromism,  while  the  medium  dose  seems  to 
be  better  api^ropriated,  but  will  do  just  as  much  mischief  in  the  way  of 
bromism  as  the  larger  one,  if  given  for  a  length  of  time.  My  records 
show  me  that  the  average  time  for  development  of  symptoms  of  this  kind 
is  about  three  months,  while  amesthesia  of  the  fauces  is  produced  in  a  few 
weeks,  or  even  a  much  shorter  time  ;  and  I  agree  with  others  that  it  is 
necessary  to  produce  this  condition  before  we  can  say  that  the  medicine 
has  produced  its  physiological  effect.  But  when  once  reached,  the  further 
toxic  action  of  the  drug  is  deleterious  instead  of  beneficial.  Bi-own- 
Sequard  considers  the  appearance  of  acne  to  be  an  indication  that  the 
medicine  has  begun  to  do  its  work,  in  which  opinion  he  is  joined  by  Dr. 
Putnam- Jacobi.'  Voisin"  considers  the  "  point  of  saturation  to  be  indi- 
cated by  the  anaesthesia  of  the  pharynx  and  nares,  so  that  in  one  case 
nausea  is  not  produced  by  titillation  with  a  spoon,  and  in  the  other  sneez- 
ing and  weeping  do  not  follow  the  introduction  of  a  straw  into  the  nasal 
cavity."  I  should  consider  the  latter  a  rather  severe  test.  According  to 
Danton,^  the  bromides  act  as  vascular  medicaments,  diminishing  excito- 
motor  power.  They  act  on  the  unstriped  muscular  fibre,  pi'oducing  local 
anaemia,  and  moderating  excitation  resulting  from  temporary  or  perma- 
nent congestion.  "  They  are  agents  that  pass  very  rapidly  into  the  blood 
(Ringer),*  and  consequently  their  effects  are  very  immediate,  and  they 
accumulate  till  the  point  of  saturation  is  reached  before  they  are  elimi- 
nated in  anything  like  considerable  amounts."  We  are  all  aware  that 
repeated  and  large  doses  of  these  drugs  are  followed  by  a  most  disagree- 
able and  pernicious  state  of  affairs.  Voisin*  has  referred  to  two  forms  of 
bromism,  which  he  has  divided,  into  the  slow  and  rapid.  In  the  first  the 
complexion  becomes  muddy,  the  eyes  sunken,  sight  and  hearing  poor,  and 
memory  obscure.  The  patient  cannot  write,  and  cannot  express  himself, 
as  he  forgets  words  ;  there  is  tremulousness.  In  the  other  variety  of  the 
sloio  form  there  is  dementia,  or  delirium  with  manical  outbursts.  Ataxia 
is  also  a  feature  of  this  variety.  In  the  rapid  form — that  with  which  we 
are  most  familiar — somnolence,  headache,  uncertain  walk,  difficulty  o 
speech,  loss  of  expression,  "  fishiness  "  of  the  eyes,  drooling  of  saliva,  etc. 
etc.,  are  the  ordinary  symptoms. 

Various  grades  of  toxaemia,  or  even  a  state  which  Voisin  calls  the  "  ca- 
chexie  bromique,"  and  which  terminates  in  a  typhoid  condition,  may  result 
from  a  reckless  use  of  this  drug. 

As  regards  the  variety  of  bromide,  I  think  the  sodic  is  the  most  reliable 
and  stable,  the  potassic  salt  varying  very  much  in  strength.     The  others 

^  Oral  communication  before  Am.  Neurological  Association. 

-  Voisin,  Archiv.  de  Medecine,  Jan.  1873. 

■'  Danlon,  These  de  Paris,  1874. 

*  Op.  cit.  p.  91. 

^  Voisin,  Arcliiv.  de  Medecine,  Jan.  1873. 


EPILEPSY. 


407 


either  have  a  tendency  to  deliquesce,  or  are  expensive.  It  will  be  advis- 
able to  keep  the  solution  in  a  tight-stoppered  bottle,  and  have  fresh  quan- 
tities put  up  constantly,  as  it  is  very  apt  to  undergo  changes — in  which 
the  bromine  is  evolved.  And  now  a  word  regarding  the  time  of  adminis- 
tration. It  has  been  shown  repeatedly  that  these  salts  are  much  better 
absorbed  when  the  stomach  is  empty.  I  have  found  also  that  a  heavy 
dose  at  night  is  apt  to  do  more  good  than  if  the  amount  prescribed  is 
equally  divided  up  through  the  day.  In  a  great  many  patients  I  have 
found  the  attacks  to  occur  at  the  waking  hour,  and  I  suppose  this  is  due 
to  the  sudden  change  in  the  cerebral  circulation.  A  mild  diffusive 
stimulant  has  overcome  this,  and  in  many  cases  warded  off  the  attack.  I 
direct  my  patients  who  have  their  convulsion  at  this  time  to  keep  a  glass 
or  a  small  quantity  of  spts.  ammonite  aromaticus  near  at  hand,  to  be 
taken  before  rising.  Cold  douches  to  the  head  are  valuable.  If  the  at- 
tacks be  irregular,  it  will  be  found  necessary  to  divide  the  dose. 

Analysis  of  Eleven  Cases  of  Epilepsy. 
S.  B. — Sodic  bromide.  P.  B. — Potassic  bromide. 


s 

Average 

o 

No.  of 

s« 

Sex  and 

Duration  of 

attacks 

Maximum     Minimum 

Diminu- 

Eemarks. 

C 

age.            disease. 

before 

dose.             dose 

tion. 

C 
I? 

1 

treatment. 

T 

Male,      15 

Since  birtli 

1-2  weekly 

S.  B.  gr.  XX.  S.  B.  gr.  xv. 

2  in  8  weeks 

Weak  intellect. 

t.  i.  d. 

t.  i.d. 

2 

Male,      22 

Two  years 

1-2  weekly 

S.  B.  gr.  XV. 

1  in  20  wk's 

Disease  followed 
sunstroke ;  treat- 
ment lasted  three 
months. 

3 

Male,      25 

One  year 

1  or  more 

S.  B.  XXV., 

S.B.  gr.  ij. 

None  in  8 

Hard  drinker. 

in  week, 

P.  B.  gr. 

weeks. 

feeble  intellect : 

sometimes 

XXX. 

potassium  salt 

many  in  a 

day 

1-2  weeklv, 

inert. 

4 

Female,  2 

IS  months 

Very  small 
doses. 

None  in  8 

Fits  followed  den- 
tition ;  rickety 

sometimes 

weeks. 

3  in  a  day 

constitution. 

5 

Female,  18 

One  year 

1  in  week 

S.  B.  gr.Kxx 

Gr.  XX. 

None  in  4 

weeks. 

Tuberculous  dis- 
ease. 

6 

Male       18 

Five  years 

4  in  week 

S    B  _r    Yv 

None  from 

No  affection  of 
intellect. 

5  weeks. 

7 

Female,  11 

Five  years 

2-3  in  week 

S.B.  gr.  xx.S.  B.  gr.  XV. 

1  in  5  w'ks 

Followed  a  blow  ; 

subject  to  head- 

ache. 

8 

Female,  17 

Several 

Sometimes'S.  B.  gr.  xv. 

None  after 

Hasbitten  tongue 

months 

4-5  daily 

treatment. 

9 

Male,      20 

19  years 

2-3  weekly 

S.B.gr.xI. 

S.  B.  gr.  XV. 

No  fits  for 
2  weeks. 

No  aura. 

10 

Male,      13 

Two  years 

3  weekly 

S.  B.  gr.xxv^S.  B.  gr.  xv. 

I  in  3  wks. 

Well  developed 

disease,  facies 

epilepticawell 

marked. 

11 

Male,      25 

11  years 

lin2  weeks 

S.  B.  gr.  XX. 

1  in  5  w'ks. 

No  fits  since  be- 

ginning of  treat- 

ment. 

By  this  table  it  will  be  seen  that  from  fifteen  to  twenty  grains  of  the 
sodic  salt  were  required  to  immediately  decrease  the  number  of  attacks. 

The  treatment  of  the  disease  in  women  should  be  directed  as  well  to  the 
pelvic  organs.  It  will  be  found  that  the  bromides  will  markedly  affect 
the  flow,  and  relieve  the  pain  or  uneasiness  which  is  connected  with  the 


408  BULBAR    DISEASES. 

menstrual  period.  Locally  I  have  found  that  cold  applied  for  a  few 
minutes  daily  over  the  ovaries  will  modify  the  attacks  should  they  be 
connected  with  irritation  of  any  of  the  pelvic  viscera.  The  progress  of 
the  disease  should  be  soon  modified  by  the  doses  I  have  recommended; 
and  it  will  be  seen  by  the  table  condensed  from  that  prepared  by  Dr. 
Hollis/  that  even  smaller  doses  modified  or  cured  the  majority  of  the 
cases  he  cites.  At  the  Epileptic  and  Paralytic  Hospital,  where  most  of 
the  cases  are  the  very  worst  that  can  be  collected  as  regards  chronicity,  I 
find  that  sixty  grains  a  day  will  cut  short  the  attacks  of  a  great  many  pa- 
tients, and  I  have  cured  a  number  of  private  patients  by  this  method. 
Dr.  Hollis'  cases  were  not  selected,  and  are  evidently  hospital  patients, 
like  my  own. 

On  succeeding  pages  will  be  found  two  tables.  In  one  are  tabulated  the 
interesting  features  of  twelve  cases  of  epilepsy.  They  are  old  hospital 
patients,  and  had  applied  for  admission  after  outside  treatment  had  been 
exhausted.  Even  here  the  bromides,  in  the  doses  I  have  given,  seem  to 
do  much  for  the  sufl:erers.  Head-injury  and  actual  insanity  make  the 
prognosis  as  bad  as  it  well  can  be,  and  treatment  is  simply  palliative. 
Large  doses  have  aggravated  many  of  those  cases. 

The  other  observations  are  selected  from  my  note-book,  and  are  illus- 
trative of  the  efficacy  of  the  dose  I  have  advocated.  Bromism  occurred 
in  spite  of  all  I  could  do  in  most  of  them,  though  it  was  a  mild  form  and 
under  control.  The  patients  were  all  of  the  better  class,  and  of  course  had 
all  the  advantages  of  comfortable  homes,  attentive  friends,  substantial 
food  and  good  air,  although  many  of  them  were  inclined  to  over  eating,  as 
in  f;)ct  all  epileptics  are.  In  this  respect  there  is  an  advantage  in  favor  of 
the  poorer  patients,  who  cannot  obtain  rich  food. 

And  now  regarding  the  large  doses.  If  the  idea  is  thoroughly  to  ruin 
the  patient's  health,  enfeeble  his  mind,  or  perhaps  drive  him  to  an  asylum, 
the  toxic  administration  may  be  indulged  in.  It  is  verytrue  that  some- 
times a  rapid  restoration  may  be  brought  about  by  "iron  and  quinine;" 
but  there  are  many  cases  where  the  recovery  is  not  quite  so  complete  as 
one  could  wish  for.  Memory  is  enfeebled,  and  there  is  a  cachexia  which 
remains  for  an  indefinite  time.  Adarker  side  of  the  picture  is  not  always 
displayed  when  brilliant  results  are  detailed.  This  is  the  list  of 
demented  and  those  that  have  died.  Dr.  Janeway  was  present  at  the 
autopsies  of  two  patients  who  died  bromiuized,  for  certainly  the  examina- 
tion disclosed  no  other  cause  of  death.  I  myself  have  seen  several 
demented  cases,  and  I  have  no  doubt  others  could  tell  the  same  story.  I 
have  used  the  bromides  in  combination  with  chloral  hydrate,  and  have 
obtained  the  most  excellent  eflfects.  Such  good  results  as  diminished 
condition  of  stupor  and  eruption,  follow  the  administration  of  equal  parts 
of  chloral  and  the  bromide  of  sodium.  The  bromides  of  ammonium 
and  sodium  with  chloral  as  recommended  by  the  N.  Y.  Therapeutical 
Society,  may  be  employed. 

1  British  Medical  Journal,  Julv  1,  1876,  p.  4. 


EPILEPSY. 


409 


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EPILEPSY.  411 

Belladouna  and  its  alkaloids  are  of  great  value  when  the  seizures  occur 
in  the  daytime,  or  are  of  the  variety  known  as  jJetit  mal.  I  have  injected 
the  sulphate  of  atropia  in  ei  gr.  doses  beneath  the  skin  at  the  back  of 
the  neck  with  good  effect,  and  have  used  it  in  the  manner  directed  by 
Trousseau.  In  either  way  it  should  be  administered  until  dryness  of  the 
throat  is  obtained,  and  should  be  given  a  patient  trial.  The  property 
possessed  by  belladonna  of  blunting  reflex  susceptibility  assures  it  a  great 
advantage  over  other  methods  of  treatment,  when  there  are  centres  of 
irritation  such  as  in  gastric  epilepsy. 

In  ergot  we  have  a  remedy  which  controls  the  cranial  circulation  much 
more  readily  than  any  drug  with  which  I  am  acquainted.  As  the  object 
is  to  diminish  the  congestion  at  the  floor  of  the  fourth  ventricle,  its  com- 
bination with  the  bromides  greatly  increases  the  action  of  the  latter. 
Ergotin  may  be  given  alone  in  the  form  of  Bonjean's  capsules. 

To  Tyrrell  ^  belongs  the  credit  of  suggesting  strychnine.  He  believes 
that  this  remedy  controls  excitation  of  the  medulla  oblongata.  In  one 
individual  who  averaged  fifty-one  attacks  in  a  month,  the  number  was 
reduced  l)y  the  strychnine  to  eleven  in  two  years.  Handfield  Jones  does 
not  favor  the  remedy,  nor  do  others,  although  it  has  advocates  in  this 
country.  In  small  doses  it  certainly  does  good  ;  but  I  have  found  that  in 
larger  doses  than  ^^  gr,,  ter  in  die,  it  rather  aggravates  the  disease. 

Arsenic  is  excellent,  both  for  its  anti-periodic  and  alterative  action,  and 
as  an  agent  to  relieve  the  acne.  Clemens,  of  Frankfort,  has  lately  advo- 
cated the  bromide  of  arsenic,  but  in  such  small  doses  as  to  seem  useless. 
He  claims  for  it  remarkable  virtue  when  the  disease  depends  upon  idiocy, 
and  appears  in  patients  with  deformity  of  the  skull.  He  reports  two 
cures. 

Dr.  Hughes  Bennet^  reports  the  results  of  the  bromide- treatment  in 
one  hundred  cases  of  epilepsy.  In  over  sixty  per  cent,  of  the  cases  decided 
benefit  resulted,  the  attacks  being  prevented  or  aborted.  In  about  thirty- 
five  per  cent,  there  was  bromism,  and  the  remainder  suffered  from  general 
enfeeblement  of  mind  or  body,  without  much  benefit  so  far  as  the  relief 
of  the  disease  was  concerned. 

Dr.  Bennet's  method  of  administration  consisted  of  doses  of  thirty 
grains  of  the  bromides  of  potassium  and  ammonium,  in  the  proportion  of 
two  parts  of  the  former  to  one  of  the  latter,  given  with  aromatic  spirits 
of  ammonia  and  water.  The  dose  was  always  given  when  the  stomach 
was  empty.     After  two  or  three  months  the  dose  was  diminished. 

Where  there  is  an  irregularity  of  heart  action,  sluggish  circulation, 
blueness  or  duskiness  of  the  skin,  I  think  digitalis  is  indicated  ;  in  fact,  I 
generally  use  it  in  every  chronic  case.  It  is  a  drug  well  tolerated  by 
epileptics,  who  can  take  it  in  surprisingly  large  dose^. 

An  agent  has  been  lately  given  to  the  profession  which  seemed  all  that 

^  Med.  Times  and  Gazette,  May  and  August,  1867. 
^  Br.  Med.  Journal,  June  7, 1873,  and  Journal  of  Kervous  and  Mental  Diseases, 
October,  1879,  p.  770. 


412  BULBAR   DISEASES. 

Fas  needed  at  first,  but  which  I  am  convinced  is  very  much  over-estima- 
ted, except  as  an  abortant.  I  speak  of  the  arayl  nitrite.  Drs.  Weir  Mit- 
chell, Zeigler,  and  Alexander  McBride,  as  well  as  several  foreign  writers, 
have  praised  it,  and  several  cures  have  been  reported.  In  epilepsy  there 
seems  to  be  a  "habit  (if  I  may  use  the  expression)  or  tendency  to  period- 
icity. Amyl  is  well  adapted  to  stop  this,  as  is  any  other  remedy  of  the 
same  class.  Crichton  Browne  alludes  to  the  effects  of  this  drug  upon  the 
status  epilepticus.  His  patient  had  had  a  great  succession  of  fits,  and  was 
at  the  point  of  death ;  the  pupils  were  contracted  to  an  intense  degree, 
pulse  116,  temperature  102^,  with  stertorous  breathing.  Voluntary 
movements  and  yawning  were  caused  by  inhalation  of  the  amyl  nitrite, 
and  the  patient  subsequently  raised  his  head,  looked  about  him,  and  re- 
covered. Dr.  Browne  relates  ten  other  cases  which  were  seen  with  Dr 
Mierson. 

Dr.  C.  Stecketec^  draws  the  following  conclusions  in  regard  to  the  action 
of  this  drug  in  epilepsy  : — 

"It  exerts  an  important  influence  where  the  epilepsy  is  due  to  or  con- 
nected with  cerebral  auiemia,  for  the  reason  that  it  '  anticipates  the  attack 
when  there  are  prodromata;  cuts  oflfthe  attack  when  it  appears;  relieves 
symptoms  due  to  interruiited  innervation  after  the  attack;  and  the  attacks 
become  less  frequent.'"  He  also  considers  it  injurious  whei'e  the  attacks 
are  due  to  cerebral  hyperemia,  for  the  reason  that  they  last  longer  and 
become  more  frequent,  and  when  either  maniacal  or  convulsive,  increase 
in  intensity. 

My  own  experience  wuth  amyl  nitrite  has  clearly  settled  in  my  mind 
the  fact  that  it  has  great  virtues  in  cutting  short  or  averting  attacks,  but 
that  it  has  no  permanent  influence.  Whether  we  can  or  cannot  make  the 
delicate  distinctions  of  Dr.  Steketec,  future  clinical  experiences  I  think 
must  decide.  Those  who  have  used  it  say  that  it  does  good  in  a  very  lim- 
ited number  of  cases;  and  it  is  a  diflicult  task  to  decide  which  art  to  be 
benefited.  I  have  tried  it  in  every  grade  of  epilepsy,  and  find  in  some  of 
the  worst  cases,  where  the  fits  occur  all  through  the  day  with  very  slight 
intervals,  and  even  where  there  is  time  enough  to  be  prepared,  that  it  is 
often  of  no  avail.  It  may  be  given  inclosed  in  the  little  glass  capsules 
invented  by  Dr.  McBride,  of  New  York,  for  hospital  use,  and  for  patients 
who  are  not  intelligent,  in  alcoholic  solution. 

'Bourneville  and  d'  Oilier  have  used  the  bromide  of  ethyl  in  epilepsy 
and  hysteria,  and  have  found  that  when  it  was  inhaled  during  the  tonic 
phase  of  the  attack,  it  produced  an  abortion  of  the  subsequent  stages  of 
the  attack.  My  experience  with  the  new  anaesthetic  given  in  solution 
in  epilepsy  was  not  encouraging — but  it  may  be  given  by  inhalation  in 
place  of  amyl. 

^Berland  has  used  tartar  emetic  in  doses  sufficient  to  produce  vomiting 

1  Abstract  of  thesis  in  Chicago  Journal  of  Nervous  and  Menta!  Disease,  April, 
1874.  p.  260. 

■'  Gaz.  Med.  de  Paris,  No.  35,  1880.  ^  These  de  Paris,  1880. 


EPILEPSY.  413 

with  marked  relief  in  cases  of  violent  convulsive  chorea,  and  it  seems, 
worthy  of  trial  in  congestive  epilepsy. 

I  may  be  pardoned  for  bringing  another  renledy  to  the  notice  of  the 
profession,  and  one  that  has  never  been  used  for  this  purpose.  I  allude 
to  tri-nitro-glycerine.  Its  reputation  is  almost  enough  to  intimidate  the 
patient,  but  it  is  as  powerful  a  medicinal  agent  as  it  is  an  explosive.  The 
tenth  part  of  a  drop  touched  to  the  tongue  is  sufficient  in  a  space  of  time 
which  is  almost  inappreciable  to  produce  a  rapid  cerebral  hyperremia. 
The  face  is  flushed,  the  eyes  become  bright,  and  the  temporal  vessels 
throb,  while  at  the  same  time  there  are  marked  sensations  of  fulness.  It 
produces  more  lasting  congestion  than  doesamyl  nitrite,  is  much  safer,  and 
I  have  found  it  to  act  better  as  an  abortant  than  the  latter.  Any  good 
pharmacist  can  prepare  a  solution  containing  one  drop  to  ten  of  alcohol. 
This  can  be  further  diluted,  so  that  ten  drops  of  alcohol  shall  contain  one- 
tenth  of  a  drop  of  the  nitro-glycerine  solution.  It  may  be  kept  safe  in 
this  way,  for  alcohol  prevents  its  explosion.  A  dose  of  from  a  tenth  to 
one  drop  of  the  decimal  solution  is  sufficient  in  the  majority  of  cases. 

Last  of  all,  it  seems  almost  unnecessary  for  me  to  direct  attention  to 
that  most  familiar  remedy,  cod-liver  oil,  which  is  so  valuable  in  all  ner- 
vous diseases.  Anstie  treated  a  number  of  cases  by  cod-liver  oil  alone, 
and  cured  seven  out  of  twenty  patients  put  upon  this  plan  of  treatment. 
In  all  cases  I  am  convinced  that  it  is  a  valuable  remedy  which  is  not  appre- 
ciated as  it  should  be.  I  have  witnessed  its  great  virtues  when  the  bro- 
mide cachexia  was  profound,  and  believe  that  it  should  always  be  used  in 
delicate  subjects.  Picrotoxin,  a  remedy  recently  brought  forward,  I  have 
tried,  and  consider  valueless. 

The  subjects  of  diet  and  personal  habits  are  very  important  ones — par- 
ticularly as  the  stomach  is  so  often  the  seat  of  irritations  which  are  trans- 
mitted to  the  over-active  centres.  Beyond  the  question  of  over-eating,  it 
has  been  found  that  a  vegetable  diet  is  better  suited  to  this  class  of 
patients.  Mierson,  in  one  of  the  volumes  of  the  West  Biding  Rejoorts, 
publishes  cases,  and  makes  comparisons  between  those  epileptics  placed 
upon  a  meat  and  those  upon  a  vegetable  diet.  The  results  pointed  to  the 
superiority  of  the  latter.  As  the  greater  number  of  epileptics  have 
inordinate  appetites,  the   diet   should  be  strictly  regulated. 

It  is  a  good  plan,  I  think,  to  combine  the  remedies  I  have  alluded  to  ; 
and  I  take  the  liberty  of  presenting  a  prescription  I  have  used  for  several 
years : — 

R.  Strychnise  sulph.  gr.  j. 
Fl.  ext.  ergotse,  ^'ss- 
Sol.  potass,  arsenit.  5ij- 
Sodii  bromidi,  ^iss. 
Tr.  digitalis,  Jiij- 
Aqu£e  menth.  pip.  ad  5iv. — M. 
Sig. — A  teaspoonful  before  eating,  in  a  half  tumblerful  of  water 


41-4  BULBAR    DISEASES. 

.  If  the  attacks  be  the  form  known  as  petit  mal,  I  think  either  ergot  or 
belladonna  are  our  best  agents.  With  either  form  of  treatment  it  may  be 
found  often  necessary  to  'use  auxiliary  general  treatment.  The  syrup  of 
the  combined  phosphates,  or  the  syrup  of  the  lacto-phosphate  of  lime,  is 
a  good  adjunct;  and  salt  baths,  cold  head  douches,  regular  food,  early 
hours,  and  the  breaking  off  of  bad  habits,  will  often  cure  the  disease,  even 
Avhcn  it  has  lasted  many  years. 

As  a  last  resort,  should  continued  medication  prove  useless,  the  actual 
cautery  or  a  deep  seton  at  the  back  of  the  neck  will  occasionally  arrest 
these  bad  cases. 

A  variety  of  other  remedies  have  been  suggested  (and  the  list  of  drugs 
alone  would  fill  several  pages  such  as  this),  but  as  most  of  them  have 
been  found  inefficacious,  I  do  not  think  it  worth  while  to  further  weary 
the  patience  of  my  readers.      Galvanism  I  find  to  have  but  little  value. 


BULBAR  PARALYSIS. 

Synonyms. — Glosso-labio-laryngeal  paralysis  (Hammond) ;  Glosso- 
laryngeal  paralysis  (Trousseau);  Progressive  bulbar  paralysis  (Erb). 

In  the  year  1841  Duchenne^  first  called  attention  to  a  peculiar  group 
of  symptoms  which  were  connected  with  progressive  degeneration  of  the 
medulla  oblongata  ;  and  some  years  later  Trousseau  -  noticed  it  in  his  ad- 
mirable lectures,  and  presented  several  cases  reported  by  Davaine,''  long 
before  Duchenne's  observations  were  published,  but  which  were  before 
considered  to  be  examples  of  double  facial  palsy.  Hughlings  Jackson,* 
Dumenil,^  Charcot,®  and  Joffroy,  and  lately  Dowse,"  have  contributed 
to  the  literature  of  the  subject. 

Definition. — The  condition  under  discussion  may  be  described  as  a 
disease  characterized  by  gradual  loss  of  functions  of  parts  supplied  by 
the  nerves  taking  their  origin  from  the  medulla,  though  the  fifth  nerve 
is  rarely  affected. 

It  may  be  the  result  of  morbid  changes  which  are  limited  to  the  floor 
of  the  fourth  ventricle ;  or,  this  region  may  be  the  chance  site  of 
sclerosis,  which  affects  other  parts  as  well.  Such  may  be  the  lesion, 
whether  "  pseudo-bulbar  paralysis"  (the  result  of  arterial  occlusion) 
sclerosis,  or  glosso-labio-laryngeal  paralysis  exists  ;  the  special  symptoms 
are  alike,  and  they  appear  one  after  another  as  the  different  nerves  are 
involved. 


1  Op.  cit.,  2uie  edit. 

^  Lectures  on  Clinical  Medicine,  trans.,  vol.  i.  p.  908. 

3  Quoted  by  Trousseau,  vol.  i.  p.  909. 

*  Philosoplueal  Transactions,  part  i.,  1868. 

*  Gaz.  Hebdomadaire,  June,  1859,  p.  390. 

*  Archives,  de  Physiol.,  etc.,  torn,  iii.,  1870,  p.  247. 
T  Brit.  Med.  Jouto.  Nov.  4  and  11,  1876. 


BULBAR    PARALYSIS.  415 


Symptoms. — The  earliest  expression  of  the  disease  is  a  certain  loss 
of  power  of  the  lips  ;  the  lower  lip  especially.  If  the  individual  attempts 
to  whistle,  his  efforts  maybe  unsuccessful,  and  the  lower  lip  hangs  so  that 
the  mucous  surface  is  largely  exposed.  The  tongue  next  follows,  and  its 
protrusion  by  the  patient  is  a  matter  of  difficulty.  The  individual  is  un- 
able to  bring  the  tip  in  contact  with  the  roof  of  the  mouth,  and  incompe- 
tent to  use  it  in  the  formation  of  certain  consonants  (the  Unguals).  When 
he  tries  to  speak  or  read  aloud  he  finds  great  difficulty  in  pronouncing 
words  containing  the  letters  1,  n,  c,  d,  g,  h,  j,  t,  w ;  and  in  one  of  Trous- 
seau's cases  the  patient  could  not  utter  any  letter  but  a. 

He  may  remain  in  this  condition  for  some  time— say  for  a  year  or  two, 
when  the  tongue  and  lips  become  more  extensively  affected  ;  and  not  only 
are  acts  of  a  voluntary  character  impossible,  but  the  automatic  movements 
of  the  tongue  are  almost  totally  embarrassed.  The  use  of  this  organ 
in  the  management  of  food  during  mastication  and  deglutition  is  much 
impaired,  and  particles  of  food  bsoms  lodged  between  the  teeth  and  the 
gums  and  cheek. 

The  patient's  mouth  is  generally  open,  so  that  his  teeth  are  exposed 
and  from  either  side  trickles  a  glairy  stream  of  saliva.  Next  lie  cannot 
articulate  the  labials,  and  consequently  his  speech  becomes  worse  than  ever. 

He  wears  an  inane  expression,  and  is  apt  to  attract  the  atten- 
tion of  people  in  the  street  by  his  open  mouth  and  silly  appearance. 
The  condition  of  the  tongue  has  been  noted  by  Dowse;  its  papillse  become 
atrophied,  and  the  surface  very  smooth.  I  have  noticed  that  there  is  no 
loss  of  the  sense  of  taste  at  any  time. 

The  palate  next  becomes  the  seat  of  the  paralysis,  and  the  pharyngeal 
muscles  are  so  weak  that  deglutition  is  at  first  difficult,  and  finally 
impossible.  Fluids  are  especially  troublesome  to  swallow,  and  are 
apt  to  be  regurgitated  through  the  nares,  and  the  voice  becomes  nasal 
and  metallic  as  the  upper  part  of  the  vocal  apparatus  becomes  involved. 

The  facial  expression,  always  a  marked  feature  of  the  disease,  is  now 
very  pitiable.  The  tongue  lies  in  the  bottom  of  the  mouth  utterly  devoid 
of  power,  so  that  the  patient  cannot  protrude  it,  and  it  becomes  useless  for 
all  purposes.  If  the  posterior  wall  of  the  pharynx  be  irritated,  there  is 
none  of  the  reflex  response  which  is  so  marked  in  the  normal  state,  but 
only  pain  is  produced.  Such  was  the  condition  of  affairs  noticed  in  one  of 
Dr.  Dowsers  patients. 

The  epiglottis  does  not  cover  the  larynx ;  and  there  is  a  tendency  to 
choking  from  the  accidental  introduction  of  food,  so  that  eating  becomes 
a  dangerous  undertaking.  The  voice  grows  very  weak,  and  the  sufferer 
can  no  longer  even  make  the  almost  unintelligible  sounds  which  charac- 
terized the  early  stages  of  his  disease. 

His  breathing  now  becomes  very  irregular,  the  inspirations  are  quite 
slow  and  shallow,  and  he  sinks  from  sheer  exhaustion  due  to  insufficient 
nourishment  and  becomes  amere  wreck,  dragging  himself  about,  and  look- 
ing forward  to  death  as   something  which  alone  is  to  bring  relief     As  the 


416  BULBAR   DISEASES. 

pneumogastric  becomes  more  and  more  involved,  the  respiration  undergoes 
changes  which  result  in  asphyxia. 

For  some  time  before  the  eod,  his  sufferings  grow  intense.  Mucus 
collects  in  the  bronchi,  which  he  is  unable  to  remove  by  coughing,  and 
he  sits  in  his  chair  with  a  feeling  of  greater  security  than  when  lying 
down,  for  in  the  supine  position  the  saliva  finds  its  way  into  the 
larynx,  and  produces  suffocation.  Loss  of  consciousness  or  mental  impair- 
ment is  never  a  symptom  of  the  disease  unless  it  be  of  the  complicated  form. 

The  following  intei'esting  case  was  reported  recently  by  Dr.  A.  H. 
Smith,^  of  this  city: — 

The  subject  was  a  clergyman,  aged  sixty-one  years.  About  fifteen  years 
ago,  after  prolonged  and  severe  exerci-e  of  the  voice  in  preaching,  he  be- 
came hoarse,  and  ultimately  his  voice  failed  so  that  he  could  speak  only 
in  a  whisper. 

After  the  lapse  of  a  year  he  gradually  regained  the  use  of  the  larynx, 
but  as  he  did  so  he  became  sensible  of  an  imperfection  in  his  enunciation 
of  certain  syllables,  especially  those  containing  the  letters  p,  t,  d,  s,  etc 
This  difiiculty  has  increased  until  now  the  jDOwer  of  uttering  the  labial  and 
lingual  sounds  is  almost  entirely  lost. 

Later  a  difficulty  in  swallowing  was  gradually  developed,  which  has 
reached  such  a  degree  that  only  ivarm  Jiuids  can  be  taken,  and  these  with 
great  care  and  hesitation,  as  they  are  apt  to  cause  strangling,  and  to  return 
through  the  nose.  Mucus  accumulates  in  the  fauces,  which  he  has 
great  difficulty  in  getting  rid  of,  and  which  causes  a  sense  of  strangu- 
lation. 

He  finds  that  the  movements  of  the  tongue  are  very  much  restricted,  and 
he  has  not  the  full  control  of  his  lips. 

His  sight,  taste,  and  smell  are  as  perfect  as  is  usual  in  persons  of  his 
age.     The  sense  of  touch,  even  in  the  paralyzed  parts,  is  not  impaired. 

He  feels  much  less  distress  when  the  weather  is  warm,  and  dreads  the 
approach  of  each  winter. 

Such  is  the  account  which  the  patient — a  very  intelligent  man — gave 
of  himself.  As  to  the  objective  appearances,  the  patient  moved  slowly 
and  feebly,  but  this  was  evidently  the  result  of  mere  debility.  The  next 
notable  thing  at  a  cursory  glance  was  the  expression  of  his  mouth.  The 
orbicularis  muscle  was  entirely  paralyzed,  permitting  the  lower  lip  to  fall 
avpay  from  the  upper,  and  to  become  partly  everted  There  was  also 
relaxation  and  eversion  of  the  upper  lip  from  the  same  cause.  The  leva- 
tores  menti  and  the  deprcssores  ang.  oris  were  not  involved  iu  the  pa- 
ralysis, and  by  their  aid  the  patient  was  able  to  bring  the  lips  into  contact ; 
but  when  so  approximated  they  projected  forward,  leaving  a  space  be- 
tween them  and  the  teeth,  and  giving  a  very  peculiar  expression  to  the 
face. 

When  the  mouth  was  opened  the  movements  of  the  tongue  were  ob- 
served to  be  very  slow  and  very  much  restricted.  The  tip  could  not 
be  turned  upward  to  touch  the  roof  of  the  m  juth,  nor  backward  beyond 
the  bicuspid  teeth.     The  tongue  was  not  notably  changed  in  shape  or  size. 

All  the  muscles  of  the  soft  palate,  includiug  the  palato-pharyngi 
and  palato-glossi,  were  paralyzed,  so  that  when  the  head  was  thrown 

iMed.  Kecord,  Nov.  2t,  1877. 


BULBAR    PARALYSIS.  417 

backward  the  relaxed  velum  fell  of  its  own  weight  against  the  posterior 
wall  of  the  pharynx.  The  finger  carried  into  the  fauces  produced  scarcely 
any  local  reflex  action,  showing  that  the  constrictors  were  complicated ; 
but  sensation  was  perfect,  and  the  reflex  action  of  the  stomach  seemed 
unimpaired,  efforts  at  vomiting  being  readily  excited. 

There  was  a  very  profuse  secretion  of  mucus  from  the  larynx  and 
pharynx,  which  was  gotten  rid  of  with  the  utmost  diflGcalty.  There  being 
perfect  inability  to  contract  the  cavity  of  the  pharynx,  the  air  which  was 
forced  from  the  larynx  in  the  act  of  hawking  escaped  into  a  great  loose 
bag,  instead  of  into  a  narrow,  firm  passage,  and  thus  it  failed  to  drive  the 
mucus  before  it.  The  paralysis  of  the  soft  palate  added  to  the  difficulty, 
for  when  by  great  labor  a  portion  of  mucus  was  coughed  up  into  the  back 
part  of  the  mouth,  the  non-closure  of  the  isthmus  faucium  permitted  it  to 
fall  back  again  upon  the  larynx. 

Examination  with  the  mirror  showed  that  the  laryngeal  muscles  re- 
tained their  activity,  and  the  cords,  with  the  exception  of  slight  hyperaj- 
mia,  were  normal.     The  respiratory  muscles  were  as  yet  unimpaired. 

In  this  case  it  is  not  probable  that  the  loss  of  voice,  which  occurred  in 
the  early  stage  of  the  disease,  was  owing  to  a  central  lesion,  since,  after  a 
year  had  passed,  the  larynx  gradually  regained  its  power.  Moreover, 
laryngeal  paralysis  of  bulbar  origin  does  not  usually  occur  in  this  asso- 
ciation until  after  the  paralysis  of  the  lips,  tongue,  and  soft  palate  has 
become  well-marked.  It  is  more  than  probable  that  the  aphonia  was  the 
result  of  a  catarrhal  affection,  and  that  if  life  continues  long  enough, 
there  will  be  a  return,  but  this  time  from  advancing  chano-e  iu  the  me- 
dulla. ° 

_  The  greater  ease  in  swallowing  imrm  fluids  is  characteristic  of  dyspha- 
gia from_  almost  any  cause.  Thus  it  is  observed  in  both  organic  and 
spasmodic  stricture  of  the  oesophagus,  and  also  when  dysphagia  results 
from  the  pressure  of  a  tumor. 

Dowse  ^  considers  the  disease  to  be  either  progressive,  stationary,  or  re- 
trogressive, and  if  it  were  not  for  the  single  case  of  the  last  variety,  which 
he  publishes,  I  should  not  be  prepared  to  accept  the  two  latter  divisions 
This  he  calls  reflex  bulbar  paralysis.  His  patient,  a  woman  aged  59,  suf- 
fered from  Bright's  disease  and  inflammation  of  the  maxillary  and  parotid 
glands.  ^  After  her  recovery  from  the  last-mentioned  condition,  there  was 
paralysis  of  the  hypoglossal,  facial,  and  spinal  accessory  nerves,  as  well 
as  the  third  division  of  the  fifth.  The  vocal  cords  acted  feebly,  and  she 
could  scarce  speak  in  a  whisper,  being  able  to  pronounce  only  the  liu- 
guals  r  and  s,  and  could  not  protrude  her  tongue ;  food  lodged  in  the 
cheeks ;  saliva  dribbled  from  the  mouth ;  she  was  unable  to  blow  out  a 
candle,  while  deglutition  was  interfered  with  to  some  extent.  Strange  to 
say,  there  has  been  improvement.  It  would  be  well,  however,  if  Dr. 
Dowse  had  allowed  a  longer  time  to  elapse  before  coming  to  a  conclusion 
in  regard  to  the  retrogressive  character  of  the  disease  in  this  instance,  for 
the  parotitis  may  have  been  simply  a  coincidence.  I  am  inclined  to  think 
that  the  history  of  any  genuine  case  thus  far  reported  has  shown  a  ten- 
dency to  progressive  decline,  which,  though  delayed  in  some  instances, 
has  nevertheless  steadily  advanced  to  a  fatal  termination. 

1  Brit.  Med.  Journ.,  Nov.  11,  1876,  p.  615. 
27  '         'f 


418  BULBAR    DISEASES. 

Causes. — The  disease  is  one  of  middle  age,  and  attacks  men  more 
often  than  women.  It  is  usually  the  result  of  syphilis,  and  sometimes 
follows  exposure  and  mental  worry.  Dowse  considers  the  causes  of  the 
peripheral  symptoms  to  be  the  following : — 

Direct. 

1.  Progressive  interstitial  neuritis. 

2.  Thrombosis. 

3.  Hemorrhage.         ^ 

4.  Morbid  growths.     ^Rare. 

5.  Vascular  spasm,    j 

Indirect. 

1.  Reflex  action  from  peripheral  irritation. 

2.  Inhibition  from  shock  to  central  cerebral  ganglia. 

Morbid  Anatomy  and  Pathology. — Trousseau's  autopsies  re- 
vealed induration  of  the  medulla,  atrophy  of  the  roots  of  the  hypoglossal 
and  spinal  accessory  nerves,  thickening,  and  gray  discoloration  of  the 
dura  mater  on  a  level  with  the  medulla,  which  extended  as  far  down  as 
the  roots  of  the  fourth  cervical  pair.  "  This  thickening  was  due  to  a 
considerable  increase  in  the  amount  of  fibers  of  connective  and  fibro-elastic 
tissue,  and  seemed  to  result  from  a  chronic  congestive  process,  as  shown 
by  the  great  number  of  capillaries  and  of  deposits  of  hsematin  external 
to  them.  The  motor  nerve-roots  of  many  cervical  nerves  were  found 
thinner  than  they  should  be  from  disappearance  of  nerve-tubes.  The  fifth 
and  glosso-pharyngeal  nerve-roots  were  healthy,  and  the  muscular  tissue 
of  the  paralyzed  parts  was  found  to  be  normal." 

Dumenil  published  a  case  which  was  probably  progressive  atrophy ; 
but  some  of  the  symptoms  were  those  of  the  disease  under  consideration. 
In  this  case  there  was  extensive  atrophy  of  the  roots  of  the  hypoglossal, 
pneumogastric,  and  facial  nerves,  as  well  as  a  great  many  other  changes. 

Fox^  considers  an  absolute  or  partial  disappearance  of  the  nerve-tubes, 
with  preservation  of  the  neurilemma  at  the  nerve-roots,  to  be  a  constant 
lesion;  and  Wilks^  found  that  the  roots  of  the  hypoglossal  and  spinal 
accessory  nerves  had  undergone  atrophy,  and  become  reduced  to  "  little 
thin  gelatinous  threads." 

Sclerosis  may  occasionally  involve  the  medulla,  and  produce  symptoms 
characteristic  of  loss  of  function  in  the  nerves  to  which  I  have  alluded. 

Charcot^  gives,  among  other  cases,  one  that  involved  the  medulla  ex- 
tensively. A  patient  of  his  presented,  besides  the  ordinary  symptoms  of 
disseminated  sclerosis,  three  months  afterward,  evidences  of  invasion  of 
the  pneumogastric  and  hypoglossal  nerve-roots.  There  were  dyspnoea 
and  dysphagia.  The  patient  was  obliged  to  eat  more  slowly  ;  and  often- 
times the  food  was  regurgitated  through  the  nostrils.  Death  followed  in 
about  six  weeks  afterwards,  and  was  preceded  by  asphyxia. 

^  Op.  cit.,  p.  234.  2  Guy's  Hosp.  Kep.,  vol.  xv. 

'  Le90iis  sur  les  maladies  du  srsteme  nerveux,  Paris,  1872-73.    Premiere  partie, 
p.  234. 


BULBAR    PARALYSIS.  4l9 

The  autopsy  revealed  the  following  state  of  the  nervous  centres :  A 
section  made  one  centimetre  below  the  protuberance,  at  the  point  of  origin 
of  the  trigeminus,  disclosed  a  point  of  sclerosis.  Other  transverse  sec- 
tions were  made  at  the  smaller  part  of  the  olivary  bodies,  and  a  sclerosed 
patch  was  discovered.  Another  patch  was  seen  at  the  root  of  the  pneu- 
mogastric.  Examination  by  the  microscope  revealed  a  number  of  broken 
nerve-tubes  and  broken-down  cells  at  the  nuclei  of  the  hypoglossal,  and 
traces  of  irritation  in  the  white  substance  of  Schwann  in  the  pneumogas- 
tric  fibers.     The  pharynx  and  larynx  were  healthy. 

The  observations  of  Lockhart  Clarke  have  shown  the  intimate  rela- 
tionship of  the  nuclei  of  the  important  cranial  nerves  which  become  af- 
fected in  bulbar  paralysis.  There  is  a  set  of  nerve- cells  common  to  these 
nerves,  and  disease  of  the  nuclei  of  one  nerve  is  very  likely  to  extend  to 
others  of  the  group,  so  that  ultimately  there  is  a  general  invasion,  which 
is  bilateral  and  never  one-sided. 

The  destructive  process  is  probably  myelitis,  as  Leyden  has  suggested, 
and  disappearance  of  the  motor-cells  is  the  direct  cause  of  the  paralysis. 

It  is  a  curious  fact  that  the  sixth  nerve  invariably  escapes  when  we 
remember  that  it  arises  from  a  common  nucleus  with  the  seventh,  as 
demonstrated  by  Lockhart  Clarke  and  Stilling.  In  regard  to  the  partial 
paralysis  of  the  facial  as  an  early  symptom,  and  the  subsequent  increase 
in  the  area  paralyzed,  we  must  remember  Romberg's  statement  that  in 
organic  brain-disease  the  entire  distribution  is  not  affected,  but  that  the 
fibers  involved  are  those  that  supply  the  muscles  of  the  upper  lip  and  alse 
of  the  nose ;  and  this  is  an  important  point  in  the  diagnosis  from  periphe- 
ral paralysis ;  and  Dowse  calls  to  mind  the  fact  that  bilateral  paralysis 
of  the  muscles  supplied  by  the  facial  is  connected  with  lesion  at  the  root 
of  the  nerve. 

The  aphonia  may  result,  according  to  Dumenil,  either  from  paralysis 
of  the  thoracic  muscles,  or  those  of  the  larynx.  The  ptyalism  I  am  in- 
clined to  ascribe,  in  the  later  stages,  to  paralysis  of  the  chorda  tympani, 
but  agree  with  others  who  have  observed  it,  that  the  accumulation  of 
saliva  in  the  first  stage  is  due  more  to  the  patient's  inability  to  swallow 
it  than  to  anything  else.  Respiratory  troubles  may  be  due  to  paralysis 
of  the  pneumogastric  and  its  motor,  the  spinal  accessory. 

Dowse  has  divided  the  disease  into  three  stages  as  regards  the  diffi- 
culty of  swallowing,  the  first  of  which  is  connected  with  paralysis  of 
the  hypo-glossal;  the  second  with  paralysis  of  the  motor  branches  of 
the  glosso-pharyngeal ;  and  the  third  with  paralysis  of  the  spinal  acces- 
sory. 

Voisin,  in  speaking  of  the  alterations  in  speech,  defines  them  into  stut- 
tering, drawling,  hesitation,  jabbering,  stammering,  and  quavering.  The 
first  three  are  due  to  lesions  of  the  nerve-tracts  which  pass  from  the  an- 
terior cortex  to  the  medulla  oblongata,  and  which  traverse  the  corpora 
striata,  crura  cerebri,  and  pons,  and  are  connected  with  disturbances  of 
will.  The  other  three  have  no  such  origin,  but  depend  upon  inco-ordina- 
tion  of  the  muscles  supplied  by  the  hypoglossal,  facial,  and  glosso-pharyn- 
geal nerves. 


420  BULBAR    DISEASES. 

Diagnosis. — Facial  palsy,  general  paresis  of  the  insane,  progressive 
muscular  atrophy  and  diphtheritic  paralysis  may  suggest  themselves,  and 
some  are  rather  difficult  to  exclude,  among  them  tumor,  which  however 
is  often  attended  by  convulsive  attacks : — 

1.  Facial  palsy  may  be  suggested,  but  as  this  disease  is  of  sudden  origin, 
and  affects  other  muscles  than  those  about  the  mouth,  there  need  be  no 
reason  to  confound  it  with  bulbar  paralysis. 

2.  The  early  symptoms  of  general  paresis  of  the  insane  somewhat 
resemble  the  initial  symptoms  of  the  disease  of  which  we  are  speaking. 
There  is  tremor  of  the  tongue,  however,  in  addition  to  the  embarrass- 
ment of  speech  ;  contracted  pupils  and  subsequent  psychical  symptoms 
make  the  diagnosis  clear. 

3.  Progressive  muscular  atrophy,  rarely  attacks  the  tongue  primarily, 
and  only  one  case  has  been  reported  (by  Charcot)  where  there  were  any 
bulbar  symptoms.  The  subsequent  atrophy  of  other  muscles  will  dispel 
any  doubts  the  observer  may  have.  The  affection  of  the  medulla  is  ordi- 
narily a  final  result  of  the  extension  of  the  central  disease  in  progressive 
muscular  atrophy. 

4.  Diphtheritic  paralysis  is  symptomatized  by  initial  paresis  of  the 
muscles  of  the  pharynx,  and  the  tongue  is  seldom  involved.  A  previous 
history  of  diphtheria  will  confirm  the  cause  of  the  paralysis,  should  there 
be  a  suspicion. 

Prognosis. — As  I  have  said,  Dowse  believes  that  there  are  forms  of 
the  disease  which  may  be  cured,  viz.,  the  stationary  and  the  retrogressive. 
I  cannot  believe  that  when  once  affected  by  inflammatory  disease,  such 
extensive  alteration,  and  such  decided  symptoms  as  he  mentions,  can  ever 
be  removed. 

The  histories  of  the  cases  reported  by  the  several  observers  already 
mentioned  certainly  offer  a  gloomy  prospect  and  little  encouragement  for 
the  victim.  The  only  case  reported  as  actually  cured  was  that  of 
Cheadle,^  and  from  the  pain,  visual  trouble,  and  unilateral  paralysis,  it  is 
improbable  that  the  case  was  one  of  genuine  bulbar  paralysis. 

Raynard^  reports  a  case  of  bulbar  paralysis  with  violent  heart  dilata- 
tion, syncope  and  speedy  death.  The  heart  was  found  after  death  to  be 
greatly  increased  in  size,  and  though  its  valves  were  unaffected,  there  was 
very  decided  dilatation  of  all  the  cavities. 

Treatment. — Nothing  has  been  done  which  has  resulted  in  any  de- 
cided improvement.  I  am  sorry  to  say  that  electricity  did  no  good  in 
the  one  case  I  have  treated,  but  Duchenne^  in  several  cases  found  that 
systematic  faradisation  greatly  facilitated  articulation  and  otherwise 
helped  his  cases.  Erb  and  Benedikt  were  particularly  successful.  Dowse 
recommends  cod-liver  oil,  iron,  and  phosphorus,  but  Erb  does  not  believe 
in  the  latter. 

1  Labio-glosso  laryngeal  Paralysis,  St.  George's  Hosp.  Eeports,  vol.  v.,  1871,  p.  123. 

2  Quoted  by  Pitres  in  his  Thesis,  1878. 
'De  I'electrisation,  etc,  2d  Ed.  p.  649. 


CEREBRO-SPINAL    MENINGITIS.  421 


CHAPTEE   XIY. 

CEREBRO-SPINAL  DISEASES. 
CEREBRO-SPINAL  MENINGITIS. 

Synonyms. — Spotted  fever ;  Meningite  foudroyante  ;  Head  pleu- 
risy ;  Myelitis  petechialis ;  Cerebral  or  Cerebro-spinal  typhus ;  Menin- 
gite cerebro-spinale  ;  Fievre  cerebro-spinale,  etc. 

Definition. — A  disease  characterized  by  inflammation  of  the  men-r 
inges  of  the  brain  and  cord,  symptomatized  by  pain,  tetanic  spasms,  and 
herpetic  eruptions,  and  occurring  in  an  epidemic  form. 

This  most  terrible  disease  has  of  late  years  received  a  great  deal  of  at- 
tention at  the  hands  of  German  and  French  writers.  Niemeyer^  was  one 
of  the  first  of  the  former  to  direct  attention  to  the  disease ;  while  in 
France,  Broussais  and  others  wrote  extensively.  There  is  no  doubt  as 
to  the  antiquity  of  the  disease,  for  among  the  writings  of  Hippocrates  a 
nearly  perfect  description  of  the  malady  is  to  be  found.  In  our  own 
country  the  epidemic  character  of  the  affection  was  noted  by  several  of 
the  older  authors,  among  them  North ^  (1811),  Gallup^  (1815),  and 
Minor*  (1823),  and  their  contemporaries.  Outbreaks  occurred  at  Med- 
field,  Mass.,  Litchfield  Co.,  Conn.,  and  at  various  points  in  the  Eastern 
and  Middle  States  during  the  early  part  of  the  present  century.  Clymer,* 
Jones,®  and  others  have  since  written  exhaustively  on  the  subject. 

Cerebro-spinal  meningitis  is  certainly  an  irregular  disease ;  it  is  not 
contagious,  and  is_  influenced  seemingly  in  no  way  by  climate. 

Symptoms. — The  appearance  of  symptoms  is  usually  quite  sudden, 
and  their  course  is  remarkably  rapid  and  ordinarily  tends  to  a  fatal  termi- 
nation. In  exceptional  cases  pain  in  the  back,  headache,  vomiting,  or 
malaise  may  constitute  a  premonitory  stage,  which  lasts  a  few  hours ;  but 
usually  there  is  no  such  delay.  A  severe  rigor,  an  attack  of  vomiting 
which  is  followed  by  headache  of  an  intense  description,  and  an  elevation 
in  pulse  and  temperature  mark  the  commencement  of  the  trouble.  The 
child  may  present  these  symptoms,  and  in  addition  another  which  is 
invariably  pathognomonic. 

^  Treatise  referred  to  in  Niemeyer's  Text-Rook  of  Prac.  Med.,  vol.  ii.,  p.  218. 
2  Treatise  on  a  Malignant  Epidemic,  etc.,  1811. 

*  Sketches  of  Epidemical  Diseases,  etc.,  1815. 

*  Essays  on  Fevers  and  other  Medical  Subjects,  Middleton,  Conn.,  1828. 
°  Aitken's  Science  and  Pract.  of  Medicine,  pp.  492-505,  3d  Amer.  edit. 

^  Med.  and  Surg.  Memoirs,  pp.  412-507. 


422 


CEREBRO-SPINAL    DISEASES, 


TJie  head  is  drawn  bachvards  and  downwards,  and  the  muscles  at  the 
back  of  the  neck  are  rif/idlj/  contracted.  When  the  head  is  forced  forward, 
or  when  the  child  bends  forward  to  drink,  the  pain  is  greatly  aggravated. 
At  the  same  time  the  pupils  are  contracted.  The  child  moans  constantly, 
and  is  restless ;  this  is  an  early  symptom,  and  may  appear  at  the  end  of 
twenty-four  hours,  and  be  the  first  to  attract  our  attention. 

Fi-.  59. 


(J.  Lewis  Smith.) 

The  pulse  is  now  quite  rapid,  and  may  beat  100  to  120  per  minute. 
The  pain  meanwhile  increases,  and  affects  the  head  as  well  as  the  entire 
length  of  the  spine,  and  is  increased  by  pressure.  Just  as  in  other  forms 
of  meningitis,  the  movements  made  by  the  patient  aggravate  his  suffer- 
ing, and  he  usually  strives  to  keep  quiet.  He  is  conscious  for  the  first 
two  or  three  days  should  he  live  so  long,  but  at  the  end  of  this  time  he 
loses  his  intelligence  after  first  growing  delirious.  The  pulse,  tempera- 
ture, and  respiration  are  increased.  The  former  sometimes  beats  130  per 
minute,  while  the  thermometer  may  indicate  an  advance  of  104°,  but  it 
usually  remains  at  about  100°.  At  an  early  period  crops  of  herpes  ap- 
pear upon  the  face  and  limbs,  and  the  skin  is  hypenesthetic,  and  the 
patient  cannot  bear  handling.  After  the  first  ninety-six  hours  the  con- 
vulsions succeed  the  primary  rigidity.  Opisthotonos  or  other  tetanic  con- 
tractions make  their  appearance.  Stupor  follows,  and  he  dies  in  a  condi- 
tion of  coma  ;  and  according  to  Niemeyer  death  takes  place  with  symptoms 
of  oedema  of  the  lungs.  The  bowels  are  constipated  during  the  entire 
disease,  and  during  the  later  stages  the  jmtient  has  involuntary  discharges 
of  urine. 

The  above  description  is  of  an  ordinary  case.  There  are  great  varia- 
tions, and  either  death  may  take  place  in  a  few  hours,  or  there  may  be  a 
tardy  convalescence  accompanied  by  structural  changes  of  a  very  serious 
nature.  The  course  of  the  disease  may  open  with  chill  followed  by  rapid 
convulsions  and  coma,  when  the  patient  may  die  in  less  than  twenty-four 
hours. 

In  other  cases,  after  the  subsidence  of  the  acute  symptoms,  which  may 
last  for  a  week  or  two,  convalescence  takes  place,  attended  by  headache 


CEREBRO-SPI^"AL    MENINGITIS.  423 

and  muscular  contractions,  "wliicli  continue  for  some  time.  Deafness  very 
often  results ;  and  I  have  several  times  met  with  total  loss  of  vision,  and 
paralysis  of  some  of  the  facial  muscles.  In  one  case  brought  to  me  from 
the  interior  of  the  State,  there  was  rigid  contraction  of  the  muscles  at  the 
back  of  the  neck  ;  and  in  another,  seen  with  Dr.  F.  H.  Rankin,  now  of 
Newport,  besides  ptosis,  and  paralysis  of  the  pharynx,  there  was  an  otor- 
rhoea  with  extensive  middle-ear  disease.  This  patient  was  quite  an  im- 
becile, intellectual  impairment  having  begun  after  the  subsidence  of  the 
acute  stages.  One  of  these  chronic  cases  has  been  under  observation, 
for  several  years,  but  I  have  been,  unable  to  effect  more  than  trifling 
improvement. 

Causes. — Epidemic  cerebro-spinal  meningitis  seems  to  be  much  more 
common  during  cold  weather,  and  is  much  oftener  met  with  during  infancy 
than  at  any  other  period  of  life.  Adults  are  not  exempt ;  but  the  disease 
prefers  the  young.  It  is  a  disease,  like  typhus,  which  usually  attacks 
the  poor ;  and  bad  ventilation  and  insufiicient  food  seem  to  prepare  the 
way  for  epidemics.  In  the  city  of  New  York  the  first  outbreak  of  the 
disease  appeared  in  1866  ;  and  subsided,  to  reappear,  February,  1872. 
In  the  sparsely  settled  wards  of  the  city  (the  19th,  20th,  22d),  where 
building  was  going  on  and  fresh  earth  turned  up,  it  seemed  to  prevail. 
There  were  45  fatal  cases  during  the  winter  quarter  in  these  wards,  while 
the  entire  number  of  deaths  in  New  York  during  the  same  period  from 
this  cause  was  108.  During  the  spi'iug  quarter  there  were  492  deaths,  148 
being  in  these  wards.  It  subsided  in  the  spring  of  1873,  but  reappeared 
during  the  autumn  of  that  year.  It  would  seem,  from  these  statistics,  that 
overcrowding  had  but  little  to  do  with  the  disease,  but  that  bad  drainage 
(this  portion  of  the  city  being  imperfectly  drained)  had  undoubtedly  some 
influence. 

Morbid  Anatomy. — The  meninges  of  the  brain  show  evidences  of 
intense  hypersemia,  the  sinuses  being  distended  with  blood  which  slowly 
coagulates,  and  the  dura  mater  is  the  seat  of  ecchymotic  spots.  There  is 
usually  a  sero-purulent  exudation  beneath  the  arachnoid,  and  this  is  found 
at  the  base  of  the  brain  as  well  as  in  the  ventricles.  It  may  be  recognized, 
also,  in  the  different  fissures  and  sulci.  The  spinal  meninges  are  the  seat 
of  the  same  exudation,  it  being  found  beneath  the  dura,  or  between  the 
arachnoid  and  the  pia  mater.  All  of  the  spinal  membranes  are  vascular, 
and  opaque  in  spots.  The  exudation  appears  to  be  confined  to  the  poste- 
rior parts  of  the  cord ;  and  usually,  when  infiltration  in  the  cord  has  taken 
place,  small  elevations  may  be  observed  beneath  the  pia  mater.  Accord- 
ing to  the  German  pathologists,  the  cervical  portion  of  the  pia  mater  is 
not  commonly  the  seat  of  exudation.  The  membranes  are  often  adherent, 
and  patches  of  false  membrane  are  visible,  so  that  sometimes  the  sub-cere- 
bral nerve-trunks  are  bound  together  and  connected  by  bridges  of  organ- 
ized lymph.  The  nervous  tissue  proper  is  extensively  softened  in  rare  cases- 
especially  if  the  inflammatory  action  has  been  at  all  severe.  Spots  of 
localized  softening  are,  however,  not  uncommonly  observed. 

Diagnosis. — Cerebro-spinal  meningitis  sometimes  resembles  certain 


424  CEREBRO-SPIXAL    DISEASES. 

irregular  forms  of  malignant  malarial  fever,  on  account  of  intermissions 
in  the  febrile  state.  This  is  the  case  more  especially  during  convalescence, 
when  the  affection  assumes  a  periodical  character.  The  chill  in  cerebro- 
spinal meningitis  is  not  so  marked  as  in  the  true  malarial  affection,  and 
contractions  of  the  muscles  are  rare  in  any  form  of  malarial  trouble.  The 
other  points  of  difference  may  be  thus  summed  up : — 

CEREBRO-SPINAL  MENINGITIS.  CONGESTIVE    PERNICIOUS     MALARIAL 

^         .  -1  FEVER. 

Bowels  constipated.  jS^ot  usually  so. 

Pulse   and   temperature   do  not   suffer  Both  subject  to  great  variations,  feeble 

rapid  variations.  and  irrej^ular  (Jones). 

Temperature  does  not  undergo  periodi-  Temperature  undergoes   decided   peri- 

cal  changes.  odical  changes. 

Face  Hushed  ;  eruption.  Complexion  sallow. 

Delirium  and  coma  not  affected  by  large  j^\i  symptoms  modified  usually  by  nega- 

dosts  of  quinine.                       _  tiy^  treatment  with  quinine. 

Increase  of  fibrin,  andj  rapid  coagula- 
tion of  blood  when  drawn. 

A  malignant  typhus,  or  a  masked  variola,  might  counterfeit  cerebro- 
spinal meningitis  ;  or,  on  the  other  hand,  acro-uarcotic  poisoning  might 
simulate  the  affection.  The  presence  of  tetanic  spasms  of  the  post-cervical 
muscles  is,  however,  so  prominent  a  symptom  that  when  it  is  absent  the 
improbability  of  cerebro-spinal  meningitis  is  considerable. 

Prognosis. — This  disease,  like  other  forms  of  meningitis,  has  a  bad 
character.  Death  is  generally  the  rule,  recovery  the  exception.  In  the 
city  of  New  York  the  total  number  of  deaths  from  all  causes  was  29,084 
during  the  twelve  months  ending  Dec.  31,  1873.  Of  these,  9593  were 
placed  under  the  head  of  zymotic  diseases  ;  and  the  number  of  deaths  due 
to  cerebro-spinal  meningitis  was  290.  Of  these,  69  were  under  one  year, 
and  164  under  live  years.  Very  few  cases  were  over  thirty.  In  the  ma- 
jority of  cases  the  disease  runs  its  course  in  from  4  to  20  days.  In  fatal 
cases  death  occurs  generally  before  the  12th  day. 

Treatment. — In  regard  to  treatment,  little  can  be  said  that  will  be 
encouraging.  The  ordinary  antiphlogistic  treatment,  consisting  of  ab- 
straction of  the  blood  by  leeches  applied  to  the  mastoid  processes,  and  blad- 
ders of  ice  to  the  head,  and  large  doses  of  calomel,  according  to  some  ob- 
servers, have  cut  short  the  disease,  especially  when  these  remedies  were 
used  at  its  commencement.  The  almost  wonderful  results  that  have  fol- 
lowed the  use  of  ergot  in  large  doses  suggest  this  remedy  to  us,  and  I 
have  no  doubt  that  it  will  prove  to  be  very  efficacious.  Ziemssen  recom- 
mends morphine,  and  has  never  observed  any  unpleasant  effects  following 
its  employment. 

CEREBRO-SPINAL  SCLEROSIS. 

Synonyms. — Sclerose  en  plaques  disseminees  (Charcot  and  Bourne- 
ville) ;  Insular  sclerosis  (Moxon). 

Definition. — A  disease  of  the  human  system,  the  essential  lesions  of 
which  are  patches  of  neuralgic  degeueratiou  irregularly  scattered  through 


CEPvEBRO-SPINAL    SCLEROSIS.  425 

the  nervous  substances  of  the  brain  and  spinal  cord,  and  involving  chiefly 
the  motor  tracts. 

For  a  long  time  this  disease  was  mistaken  for  paralysis  agitans  (Park- 
inson's disease),  chorea,  and  other  neuroses;  and  even  after  it  had  been 
shown  to  be  a  separate  neurosis  a  certain  amount  of  confusion  existed  in 
regard  to  its  nomenclature  and  its  position  among  the  scleroses.  Charcot 
and  Moxon^  were  the  first  to  give  it  a  distinct  character. 

Symptoms. — We  may  divide  the  progress  of  the  disease  into  three 
stages. 

1st  Stage. — The  first  symptom,  which  is  common  to  several  other  neu- 
roses, is  gradual  loss  of  power  in  the  lower  limbs,  which,  by  itself,  does 
not  attract  attention  to  the  grave  nature  of  the  disease  in  its  iucipiency. 
With  the  weakness  there  is  no  atrophy  and  no  loss  of  sensation,  while 
reflex  excitability  is  either  normal  or  only  slightly  increased.  The  rec- 
tum is  not  afiected,  nor  is  the  bladder,  and  there  is  simply  a  paresis  which 
lasts  for  a  variable  time,  perhaps  for  two  or  three  months,  or  for  a  much 
longer  period.  The  partially  paralyzed  limbs  become  agitated  by  tremors, 
which  are  seen  best  when  the  patient  takes  some  constrained  position,  or 
attempts  to  walk  a  straight  line.  He  may  have  the  gait  of  an  ataxic,  but 
generally  the  walk  is  more  like  that  of  a  general  paralytic,  being  charac- 
terized by  weakness  of  the  extremities.  As  the  disease  invades  a  higher 
portion  of  the  cord,  we  will  find  tremor  of  the  upper  limbs  and  paralysis 
of  the  cranial  nerves,  indicated  by  symptoms  I  shall  describe  in  speaking 
of  the  descending  variety.  I  may  allude,  however,  to  a  particular  defect 
in  articulation,  the  patient  being  unable  to  pronounce  some  of  the  labial 
consonants. 

2d  Stage. — Rigidity  of  the  limbs  supervenes,  with  various  contractures 
of  a  spasmodic  character,  and  exaggeration  of  the  tremor.  One  of  my 
patients  died  in  her  bed  with  her  knees  drawn  up  to  her  chin,  her  legs 
flexed  on  the  thighs,  and  her  arms  drawn  closely  to  her  chest.  It  re- 
quired quite  violent  exertion  for  me  to  extend  the  limbs,  and  the  tremor 
was  markedly  aggravated  when  I  did  so.  Electro-muscular  irritability  is 
next  greatly  increased,  and  reflex  excitability  heightened.  Epileptiform 
attack  may  now  appear,  as  well  as  apoplectiform,  and  death  may  occur 
at  this  period  from  the  invasion  of  some  cerebral  vessel  and  consequent 
cerebral  hemorrhage. 

Zd  Stage. — This  stage  is  marked  by  rapid  decline  of  the  patient's 
strength.  Incontinence  of  urine  and  feces,  bedsores,  and  dementia  follow, 
and,  after  other  evidences  of  gradual  wasting  away,  death  may  end  the 
scene. 

The  course  of  this  form  is  :  First,  paresis  of  lower  extremities  and 
tremor  ;  second,  contraction,  and  aggravation  of  tremor ;  third,  general 
dissolution.    " 

1st  Stage  of  Descending  Form :  This  is  the  condition  of  afiairs  when 

^  Eight  cases  of  insular  sclerosis  of  the  brain  and  spinal  cord,  by  W.  Moxon,  M.  D., 
Guy's  Hospital  Eeports,  vol.  xx.,  1875. 


426  CEREBRO-SPINAL    DISEASES. 

the  cord  is  attacked  secondarily.  "When  the  disease  begins  in  the  brain, 
the  early  symptoms  may  be  headache,  convulsions,  vertigo,  or,  what  is 
more  common,  paralysis  of  some  of  the  cranial  nerves  ;  there  may  be 
ptosis,  strabismus,  loss  of  hearing,  and  facial  paralysis,  or  troubles  of 
speech  and  embarrassment  in  swallowing.  The  important  symptom  next 
in  advance  is  the  appearance  of  tremor,  which  is  first  seen  in  the  tongue, 
which,  when  protruded,  trembles  visibly ;  or  it  may  affect  the  lips,  as  may 
be  noticed  when  the  patient  speaks.  The  eyeballs  oscillate  (nystagmus), 
and  the  head  may  become  agitated,  and  afterwards  the  upper  extremities. 
A  peculiarity  characteristic  of  all  forms  of  sclerosis  is  not  absent  here, 
viz.,  the  aggravation  of  tremor  by  voluntary  efforts  made  to  control  it, 
and  its  diminution  during  rest.  If  the  individual  attempts  any  complex 
action,  he  is  utterly  unable  to  complete  it  properly,  for  the  movements 
increase  until  muscular  control  is  entirely  lost.  I  have  alluded  to  the  lost 
sense  of  location,  which  is  also  seen  in  advanced  locomotor  ataxia,  and  I 
may  state  that  it  is  also  a  symptom  of  this  form  of  sclerosis. 

2d  Stage :  The  limbs  lose  their  power  to  a  great  extent  as  the  disease 
advances,  and  permanent  contractures  of  the  upper  and  lower  limbs, 
which  by  this  time  are  affected,  render  the  patient  very  uncomfortable. 
His  forearms  may  be  flexed,  and  the  fingers  are  doubled  up,  as  is  the  case 
in  uncomplicated  lateral  sclerosis.  The  thighs  are  even  flexed  on  the 
pelvis,  and  the  legs  may  be  as  well.  The  knees  are  approximated  quite 
forcibly,  and  it  is  often  difficult  to  separate  them.  This  stage  may  last  for 
several  years. 

3d  Stage  :  Meanwhile  the  tremor  has  continued,  and  increased  in  vio- 
lence ;  but  it  may  sometimes  be  stopped  by  flexing  the  great  toe,  just  as 
Brown-Sequard  has  shown  may  be  done  in  epilepsy.  The  bladder  and 
rectum  are  now  involved,  and  the  patient  suffers  terribly  from  cystitis, 
and  is  prostrated  by  diarrhoea.  Bedsores  form,  and  he  gradually  sinks 
into  a  state  which  invariably  has  a  fatal  termination.  In  both  varieties 
there  is  great  difficulty  in  articulation,  and  disturbance  of  function  in 
those  organs  supplied  by  the  lower  cranial  nerves.  The  lower  lip  falls, 
and  there  is  dribbling  of  saliva,  while  food  often  remains  in  the  mouth 
wedged  between  the  teeth  and  between  the  gums  and  cheek,  and  liquids 
find  their  way  through  the  nostrils.  Beyond  slight  irritability  and  rest- 
lessness, there  are  usually  no  mental  symptoms  at  the  outset,  or  until  the 
fixed  stage,  when  sometimes  there  is  intellectual  as  well  as  physical  de- 
cay ;  but  this  is  not  the  rule.  A  case  which  seems  to  be  of  great  interest, 
because  of  the  atrophy  of  the  upper  limbs,  came  under  my  notice  two 
years  ago. 

E.  W.,  aged  37,  salesman,  no  family  history  of  nervous  trouble.  Father 
and  mother  alive  ;  nothing  to  account  for  his  present  condition.  Five 
years  ago  he  was  employed  in  a  drygoods  store,  and  his  attention  was 
called  to  a  slight  weakness  in  his  thumb  and  forefinger  of  the  right  hand 
when  he  used  his  scissors.  There  was  subsequent  tremor,  which  annoyod 
him  excessively,  and  which  subsequently  became  quite  general.  About 
the  same  time  he  was  subject  to  very  severe  headache,  vertigo,  and  some- 


CEREBRO-SPINAL    SCLEROSIS.  427 

times  vomiting.  The  tremor  meanwhile  increased,  ?nd  ifc  became  so  "s-io- 
lent  when  he  attempted  to  execute  some  fatiguing  act  that  he  was  forced 
to  desist.  He  next  noticed  that  his  vision  was  beginning  to  be  impair.ed, 
that  he  saw  double,  or  that  "  mist  floated  before  his  eyes."  The  tremb- 
ling continued,  and  when  he  came  to  me  I  found  his  condition  to  be  as 
follows  :  The  patient  is  a  tall  man,  of  decidedly  nervous  temperament, 
quite  feeble  and  emaciated,  and  very  much  depressed.  Both  arms  are 
convulsed  by  tremors,  but  especially  the  right.  The  biceps  and  the  ex- 
tensors of  the  hand  are  much  atrophied,  and  there  is  great  loss  of  power. 
He  tells  me  that  the  tremor  has  been  much  more  violent  than  it  is  now. 
The  sensibility  of  the  cutaneous  surface  is  rather  lowered,  and  there  is  a 
certain  amount  of  analgesia,  so  that  pins  may  be  run  into  the  dorsal 
aspect  of  the  forearm  without  producing  pain.  He  was  able  to  press  the 
fluid  in  the  dynamometer  up  to  7.50  with  the  right,  and  to  17  with  the 
left.  There  is  still  headache  at  times,  and  some  dizziness.  The  left  eye- 
lid seems  to  cover  the  eyeball  more  fully  than  the  right,  and  the  muscles 
of  the  left  side  of  the  face  were  trembling  quite  violently.  When  I  told 
him  to  whistle,  his  lips  trembled  so  much  that  he  could  not  do  so ;  and 
when  I  requested  him  to  repeat  the  line  "  Ben  Battle  was  a  solider  bold," 

('tutter)  (hesitation)  (slow)  (explosion)  (explosion)* 

he  did  it  as  follows  :  "  Me-e-n  m-m-m-etta  was  a  s  o  o  g  a  m-mold."  His 
articulation  was  quite  defective,  and  I  had  great  difficulty  in  understand- 
ing him.  His  tongue  trembled,  and  his  lower  lip  seemed  to  sag  and  fall 
forwards,  and  he  was  obliged  to  wipe  his  mouth  quite  constantly,  as  there 
was  a  considerable  escape  of  saliva.  When  I  told  him  to  hold  his  head 
in  such  a  position  that  I  might  examine  his  eye  with  the  ophthalmoscope, 
it  shook  to  a  great  degree,  and  I  had  difiiculty  in  illuminating  the  retina. 
He  says  this  is  recent,  and  that  his  head  was  not  affected  by  tremor  until 
a  month  or  two  ago.  His  mind  is  clear,  and  his  memory  unimpaired. 
I  have  seen  him  but  once,  and  there  has  been  no  advance  in  his  condi- 
tion. 

The  following  case  is  reported  by  Bourneville : — ^ 

Rosine  Spitale,  20  years  old.  At  17  years  of  age  she  was  suddenly 
affected  (after  crossing  a  small  stream  and  becoming  chilled)  with  loss  of 
power,  first  in  the  right  lower  extremity,  and  then  in  the  left,  and  some 
time  after  the  hands  began  to  tremble.  At  18  there  was  some  subsequent 
improvement,  but  it  was  very  slight.  Soon  afterwards  menstruation 
ceased,  and  some  time  after  this  the  symptoms  reappeared.  Hemiplegia 
occurred  without  loss  of  consciousness  or  convulsions,  and  the  tongue  and 
eyes  were  involved.  The  disturbances  of  sensation  were  moderate ;  there 
Avas  a  certain  amount  of  numbness  in  the  lower  limbs,  and  a  sense  of  clum- 
siness of  the  tongue,  with  difficulty  in  articulation,  and  some  diminution 
of  mental  power.  At  the  beginning  of  1853  the  patient  was  well  nourished. 
A  half  grain  of  strychnine  daily  has  produced  an  amendment  for  ten  or 
twelve  days.  Electrization  produced  movements  in  the  lower  limbs,  and 
increased  the  trembling  in  the  upper  extremities.  In  the  course  of  the 
month  ihe  paresis  of  the  inferior  extremities  was  nearly  complete,  the 
trembling  of  the  eyes  with  dilatation  of  the  pupils  is  quite  pronounced, 
and  the  patient  has  become  very  stupid. 

*  The  intonation  was  very  much  like  what  we  would  expect  to  find  in  "  cleft 
palate." 

1  La  Sclerose,  etc.,  Paris,  1869,  p.  92. 


428  CEREBRO    SPINAL    DISEASES. 

January,  1854.  The  hands  tremble  less  than  they  did.  There  are  in- 
voluntary discharges  of  urine.  Ergot  3'j  per  day  has  been  used  for 
several  months.  It  acted  once  upon  the  sphincters,  and  seemed  to  improve 
the  weakness  of  the  limbs,  for  several  movements  were  possible. 

Spring,  1854.  Bedsore  on  sacrum. 

September.  In  a  state  of  decline ;  the  bedsore  has  extended  very  rap- 
idly ;  pain  in  the  head  ;  pulse  136. 

October.  Repeated  rigors ;  sensibility  of  the  inferior  limbs  returned ; 
feebleness  of  the  extensors  of  the  back ;  scoliosis  toward  the  right ;  the 
trembling  in  the  extremities  persists. 

November  1.  Death,  preceded  by  involvement  of  the  muscles  of  the 
pharynx. 

Autopsy. — The  gray  matter  is  hard;  the  nervous  substance  in  the 
neighborhood  of  the  lateral  ventricles  and  that  of  the  protuberance  were 
hard.  We  found  gray  nodules  superficial  and  deep.  The  white  substance 
had  become  hard  in  spots.  Beneath  the  microscope  the  indurated  nodules 
(white)  consisted  of  a  fibrous,  moss-like,  connective  tissue  ;  the  elements 
of  the  nervous  matter  had  almost  entirely  disappeared ;  and  the  white 
nodules  were  pressed  beneath  the  surface  of  the  cut.  The  spinal  cord 
was  indurated.     The  great  vessels  and  viscera  were  healthy. 

Dr.  Geo.  S.  Gerhard  ^  has  presented  the  following  interesting  case  of 
this  disease: — 

Samuel  A.,  set.  57,  a  native  of  Ireland,  and  a  blacksmith  by  trade, 
was  admitted  into  the  out-patient  department  of  the  Infirmary  for  Nervous 
Diseases  on  September  17,  1876,  and  gave  the  following  history.  His 
health  had  always  been  good  until  about  seven  years  ago,  when,  after  no 
known  cause,  he  began  to  lose  power  in  the  legs.  One  year  after  this  his 
arms  grew  weak,  and  he  then  observed  for  the  first  time  that  any  move- 
ment of  the  upper  or  lower  extremities  was  accompanied  by  tremor.  At 
a  somewhat  later  period  his  speech  became  affected.  The  weakness  of 
his  limbs  and  the  trembling  gradually  increased,  until  finally,  about  four 
years  ago,  he  was  obliged  to  give  up  work. 

On  admission  there  is  decided  loss  of  power  in  the  upper  and  lower 
extremities,  and  upon  his  attempting  to  use  either,  a  large  and  jerky  tremor 
is  developed.  He  walks  with  the  assistance  of  a  cane,  but  his  movements 
are  slow,  and  his  feet  clear  the  ground  with  much  difficulty.'  His  grip, 
particularly  that  of  the  right  hand,  is  feeble,  squeezing  the  dynamometer 
with  the  former  to  100"^  and  with  the  latter  to  110^.  In  the  upper  ex- 
tremities the  trembling  is  especially  well  shown  during  the  performance 
of  an  act  requiring  some  little  time  for  its  execution,  such  as  lifting  a  glass 
of  water  to  tlie  mouth.  The  tremor  also  involves  the  muscles  of  the  head 
and  trunk,  but  it  ceases  entirely  when  the  patient  is  in  a  state  of  absolute 
repose.  There  is  no  muscular  wasting,  no  loss  of  electrical  response,  and 
no  disturbance  of  sensibility. 

His  mental  faculties  are  decidedly  impaired,  and  his  speech  is  thick 
and  deliberate,  there  being  a  decided  interval  between  each  word.  His 
eyesight  is  poor,  and  examination  of  the  fundus  reveals  commencing 
atrophic  changes,  as  shown  by  attenuation  of  the  vessels  and  a  general 
pallor  of  the  optic  disk  ;  there  is  also  slight  nystagmus.  The  unsteadiness 
of  gait  and  the  tremor  are  not  increased  by  closure  of  the  eyes.  His  urine 

^  Philadelphia  Medical  Times,  Xovember  11, 187^. 


CEEEBEO-SPINAL   SCLEROSIS.  429 

is  in  all  respects  normal,  and  he  has  no  loss  of  control  over  the   bladder 
or  bowels. 

Causes. — Jaccoud  is  of  the  opinion  that  sclerosis  occurs  as  a  disease 
of  childhood,  or  adult  life  up  to  45  years,  and  that  there  is  nothing  to  indi- 
cate the  special  liability  of  either  sex  ;  whilst  Charcot  considers  it  a  dis- 
ease which  is  much  more  common  among  females  than  males,  and  that  it 
rarely  appears  after  40.  Of  six  cases  I  have  recorded  their  respective 
ages  were  18,  26,  33,  37,  41,  46  ;  four  were  males  and  two  females.  Of 
eighteen  cases  collected  by  Bourn eville  fifteen  were  women  and  three  men. 
In  three  of  these  the  disease  began  between  36  and  40,  three  between  30 
and  35,  and  the  others  between  15  and  30.  Very  little  is  known  in  re- 
gard to  the  etiology  of  sclerosis  ;  but  "  moist  cold,"  emotional  excitement, 
and  venereal  excesses  are  spoken  of  by  the  different  Continental  writers 
as  causes. 

Bourneville  found  that  the  greater  number  of  his  cases  died  between  35 
and  50,  and  that  the  disease  appeared  in  most  instances  between  the  ages 
of  26  and  35.  In  one  of  my  patients  the  disease  began  at  the  5th  year, 
in  another  at  about  the  18th  year,  and  in  the  third  and  fourth  at  32,  and 
in  the  fifth  and  sixth  between  35  and  40. 

Morbid  Anatomy  and  Patholo^. — I  have  spoken  in  another 
chapter  about  the  morbid  appearances  in  sclerosis,  and  nothing  remains  to 
be  said  in  regard  to  this  particular  form.  It  is  only  a  question  of  loca- 
tion that  concerns  us,  and  after  death  we  will  probably  find  patches  of 
tissue  scattered  through  the  brain  and  cOrd.  The  antero-lateral  columns 
seem  to  be  invaded  in  nearly  all  cases,  and  this  would  appear  probable 
from  the  contractures. 

Diagnosis. — In  the  ascending  form  it  must  be  remembered  that  the 
tremor  follows  the  paresis,  while  the  descending  form  is  characterized  by 
tremor  as  a  primary  affection,  or  at  least  before  the  muscular  paresis  of 
the  extremities.  Paralysis  agitans  may  be  confounded  with  the  descend- 
ing form  of  the  advanced  disease ;  the  tremor  in  the  former  disease  is 
continuous,  and  is  often  not  aflfected  by  quieting  infl.uence  or  sleep,  but  is 
not  aggravated  by  efforts  of  the  will.  The  early  symptoms  of  this  form 
may  also  point  to  progressive  paralysis  of  the  insane,  and  to  intracranial 
tumors ;  but  the  subsequent  progress  of  the  affection,  the  development  of 
new  symptoms,  and  the  common  absence  of  neuro-retinitis,  are  sufficient 
to  remove  any  doubts  as  to  its  true  nature. 

Prognosis. — Invariably  bad. 

Treatment. — I  know  of  no  remedy  that  can  reconstruct  a  degenera- 
tion of  nerve-tissue  which  consists  in  proliferation  of  connective-tissue 
cells,  and  nerve-tube  disappearance.  Nitrate  of  silver,  tribasic  phosphate 
of  silver,  chloride  of  gold,  galvanism,  bichloride  of  mercury,  and  chloride 
of  barium  have  been  all  used.  It  seems  that  only  one  chance  may  exist 
— the  possibility  of  syphilis.  If  this  be  present,  it  is  probable  that  spe- 
cific treatment  will  be  successful.  We  are  to  improve  the  patient's  gene- 
ral condition,  and  relieve  his  tremor  either  by  conium  or  hyoscyamia,  and 
make  him  as  comfortable  as  possible. 


430  CEREBRO-SPINAL    DISEASES. 

ALCOHOLISM. 

ACUTE — CHRONIC. 

Synonyms. — Ebrietas,  Alcoholismus,  Delirium  tremens;  Mania  a 
potu,  Alcoolisme;  Trunksacht;  Chronic  alcoholic  intoxication  (Reynolds). 

Definition. — A  disease  of  the  nervous  system  resulting  either  through 
direct  action  of  alcohol  upon  its  tissues,  or  through  impairment  of  other 
organs  which  fail  to  remove  eifete  substances  from  the  blood  ;  and  symp- 
tomatized  by  mental  aberration,  and  by  various  sensorial  and  motorial 
phenomena,  usually  the  result  of  lowered  functional  activit}'. 

The  immoderate  use  of  alcoholic  beverages  is  usually  followed  by  the 
most  deplorable  consequences.  Sad  to  say,  this  condition  is  too  familiar 
to  need  any  extended  description,  as  far  as  the  appearance  of  the  patient 
is  concerned  ;  but  there  are  other  features  of  the  disease  that  need  earnest 
and  careful  study. 

The  effects  of  alcohol  upon  the  human  being  may  be  said  to  be  physio- 
logical and  pathological.  The  sensorial  alterations  are  much  more  inte- 
resting than  the  motorial,  and  of  these  we  will  speak  in  detail. 

The  imbibition  of  a  moderate  amount  of  alcohol,  as  we  know,  is  usually 
followed  by  a  general  feeling  of  comfort,  a  certain  degree  of  exhilaration. 
The  individual  is  no  longer  absorbed  in  himself.  He  is  animated  and 
gay,  his  ideas  flow  rapidly,  and  he  becomes  filled  with  greater  energy  and 
endurance.  If  the  dose  be  increased,  the  mental  functions  become  more 
active.  He  is  excited  and  demonstrative,  and  either  violent  and  noisy, 
or  tender  and  maudlin,  according  to  the  thoughts  which  have  most  en- 
grossed his  attention,  or  through  the  influence  of  temperament.  Incohe- 
rence of  speech  and  confusion  of  ideas  succeed  the  ordinary  mental  ex- 
citement, and  this  may  be  followed  by  a  condition  of  stupor,  the  individual 
becoming  perfectly  unconscious  of  injury,  and  unmindful  of  either  bruises 
or  cuts,  or  even  severe  burns.  He  may  stagger  and  fall,  and  lie  in  some 
exposed  place  regardless  of  the  blaze  of  the  sun,  the  flies,  and  the  noise. 
He  has  finally  become  reduced  to  what  Magnan '  calls  "  la  vie  vegetative." 
He  is  "  dead  drunk."  This  deep  alcoholic  stupor  may  last  for  some  time, 
and  end  the  patient's  career ;  or  he  may  become  maniacal  instead,  or 
present  the  condition  described  by  Percy ^  under  the  name  ivresse  con- 
vukive,  in  which,  with  clonic  convulsions,  he  grows  furiously  maniacal, 
grinding  his  teeth,  and  cursing  and  menacing  those  about  him.  The 
maniacal  attacks  are  no  doubt  influenced  to  some  degree  by  the  character 
of  the  illusions  and  hallucinations. 

ACUTE  ALCOHOLISM. 

Symptoms. — The  continued  use  of  alcohol  in  excess  for  a  week  or 
two,  such  as  occurs  during  an  ordinary  debauch,  is  very  apt  to  lead  to  an 

^  Kecherches  sur  les  centres  nerveux,  p.  116. 

2 ''  Art.  Ivresse  Convulsive,"  Dictionnaire  des  Sciences  MMicales,  t.  xxvi.,  p.  249. 


ALCOHOLISM,  431 

attack  of  delirium  tremens.  This  state  of  acute  alcoholism  may  also  occur 
should  the  patient,  who  has  drunk  not  necessarily  to  intoxication,  but  to 
a  degree  almost  approaching  it,  be  deprived  of  his  drink. 

One  of  the  earliest  indications  of  this  state  of  alcoholism  is  a  tremu- 
lousness  or  "  shakiness,"  which  is  quite  marked  in  the  early  part  of  the 
day,  and  is  connected  with  nausea  and  want  of  appetite.  The  patient  ia 
restless  and  irritable,  sleeps  poorly,  and  presents  an  appearance  of  dejec- 
tion and  sadness.  His  eyes  are  red  and  watery,  and  his  skin  is  of  a 
muddy  color.  His  features  are  drawn  and  haggard,  and  he  is  a  wretched 
object  indeed.  The  gastric  irritability  may  be  so  great  as  to  prevent  any 
retention  of  food,  and  the  simplest  forms  of  nourishment  are  ejected  by 
the  stomach.  Constipation  is  obstinate,  and  the  urine  is  passed  in  small 
quantities  and  loaded  with  the  urates,  so  that  a  dense  brick-dust  precipi- 
tate is  found  in  the  chamber.  The  attack  is  immediately  preceded  by 
great  excitability,  and  by  illusions  and  hallucinations,  which  grow  very 
marked  as  the  patient  becomes  noisy  and  violent.  Magnan  has  graphi- 
cally described  the  different  varieties  of  mental  trouble.  The  patient 
may  be  sad  and  utterly  dejected.  He  may  imagine  that  he  has  committed 
some  great  crime  ;  that  he  has  been  sentenced  to  death  ;  that  he  is  being 
executed ;  and  these  delusions  may  markedly  influence  the  character  of 
his  outward  expression.  In  nearly  every  case  there  is  some  delusion  of 
persecution  of  a  horrible  kind.  The  attack  usually  begins  with  halluci- 
nations of  a  visual  character,  in  which  snakes  and  other  reptiles,  devils, 
imps,  gnomes,  and  goblins  terrify  the  patient.  In  one  instance  which  I 
remember,  he  was  tortured  by  devils  who  held  lighted  candles,  and  were 
about  to  set  his  clothes  on  fire ;  in  another  case  the  patient  endeavored 
to  escape  a  falling  weight.  The  illusions  are  always  followed  by  halluci- 
nations, and  finally  by  delusions.  The  irritations  of  the  organs  of  sense 
ai'e  distorted  so  that  the  simplest  and  most  common  noises  become  changed 
by  the  patient's  disordered  imagination  into  the  most  terrible  sounds. 
The  cry  of  the  vendor  in  the  street  is  likened  to  the  despairing  shriek  of 
a  lost  soul.  The  stroke  of  the  clock,  a  funeral  bell,  and  the  voices  of 
those  in  the  room  are  supposed  to  be  the  savage  yells  of  a  howling  mob. 
The  objects  which  the  patient  sees  are  nearly  always  transformed  into 
animals,  which,  controlled  by  no  natural  laws,  run  over  the  ceiling,  or 
gallop  through  the  air.  Odors  are  reversed,  and  food  is  supposed  to  be 
poisoned.  Animals  run  over  the  skin;  sometimes  they  are  rats  or  lizards; 
and  at  others  he  may  call  attention  to  the  torture  inflicted  by  thousands 
of  needles  or  cutting  instruments.  Maniacal  outbursts  are  the  common 
feature  of  the  attack,  the  patient  seeming  to  possess  herculean  strength, 
and  it  is  sometimes  necessary  to  have  six  or  eight  strong  men  to  prevent 
him  from  throwing  himself  out  of  the  window,  or  committing  some  deed 
of  violence.  He  may  remain  in  this  condition  for  several  days  at  a  time, 
during  which  period  he  neither  sleeps  nor  eats.  His  eyes  are  bloodshot, 
and  he  sweats  profusely.     The  pulse ^  is  very  rapid,  small,  and  irritable, 

1  The  sphygmograph  has  been  employed  by  Anstie  in  cases  of  delirium  tremens, 
and  the  tracing  obtained  very  closely  resembles  that  of  the  typhoid  fevers  and  in- 
flammation.    It  is  of  a  marked  dicrotic  type. 


4^-J  CEREBEO-SPINAL    DISEASES. 

and  though  the  deep  temperature  may  reach  102°  or  103°  F.,  the  hands 
and  feet  are  cold,  and  the  i^alms  and  soles  clammy. 

When  recovery  takes  place,  the  first  change  for  the  better  is  sleep.  The 
violent  symptoms  subside  gradually  in  the  reverse  order  of  their  appear- 
ance. He  may  awake,  after  fifteen  or  eighteen  hours,  irritable,  but  not 
much  better  ;  or  there  may  be  a  lesser  degree  of  excitement,  more  sleep, 
and  gradual  improvement. 

In  other  cases  death  follows,  there  being  a  subsidence  of  the  violent  de- 
lirium, which  changes  its  character  and  becomes  muttering;  when  he 
relapses  into  a  typhoid  state,  and  gradually  passes  away. 

The  tendency  to  the  commission  of  deeds  of  violence  is  quite  charac- 
teristic of  acute  alcoholism.  Of  377  cases  observed  by  Bouchereau  and 
Magnan^  in  the  year  1870,  twenty- four  attempted  to  commit  suicide,  and 
nine  attempts  at  homicide  were  made.  These  cases  were  seen  under  re- 
straint, but  among  the  cases  which  occur  outside  of  hospitals  and  asylums, 
the  number  is  far  greater, 

Laucei'eaux  has  described  the  features  of  acute  absinthism,  which, 
however,  is  rare  in  this  country.  He  agrees  with  Magnan,  that  epileptic 
attacks  exactly  like  those  of  the  ordinary  disease  follow  the  immoderate 
use  of  absinthe.  Several  hours  after  the  toxic  dose  of  this  liquor  has 
been  taken,  the  convulsions  take  place,  and  involve  chiefly  the  muscles 
of  the  back  and  of  the  posterior  part  of  the  neck,  so  that  a  species  of 
opisthotonus  results.  These  tonic  convulsions  are  followed  by  others  of 
a  clonic  character,  affecting  chiefly  the  muscles  of  the  face.  There  is 
frothing  at  the  mouth  and  grinding  of  the  teeth.  The  muscles  of  the 
body  are  also  next  in  a  state  of  clonic  contraction.  The  actual  attack 
lasts  for  an  hour,  and  is  not  followed  by  coma.  It  is  separated  by  inter- 
vals of  comparative  quiescence.  The  jjatient  then  falls  asleep,  and,  after 
a  variable  time,  awakens  complaining  of  sensory  disturbances. 

In  an  abstract  of  Lancereaux's  article  by  Decaisne,^  an  admirable  de- 
scription of  acute  absinthism  is  given.  He  calls  attention  to  the  fact  that 
the  cry  and  coma  are  absent  in  absinthe  epilepsy,  and  the  attack  is  ii-re- 
gular,  and  resembles  a  convulsive  attack  of  a  hysterical  character. 

CHRONIC   ALCOHOLISM. 

Symptoms. — A  much  more  grave  condition  of  affairs  follows  the 
continued  use  of  large  quantities  of  alcohol,  and  no  more  hopeless  disease 
exists  than  that  of  which  we  are  about  to  speak.  While  in  delirium  tre- 
mens recovery  may  take  place,  followed  by  total  reformation,  without  any 
serious  damage  to  the  nervous  system,  the  more  serious  nerve-changes 
wrought  by  constant  saturation  can  never  be  repaired,  but  tend  to  further 
degeneration  and  decay. 

Chronic  alcoholism  begins  by  a  number  of  insidious  alterations  in  the 

1  Op.  cit.,  p.  129. 

»  Eevue  des  Sciences  Med.,  No.  33,  1881,  p.  231. 


ALCOHOLISM.  433 

nervous  substance,  whereby  its  functional  activity  is  embarrassed,  and 
minor  symptoms  at  first,  and  more  grave  ones  afterwards,  appear  very 
gradually  and  progressively. 

The  victim  of  chronic  alcoholism  may  present  the  symptoms  of  tremor 
and  loss  of  power  of  which  I  have  before  spoken.  The  tremor  is  rhyth- 
mical, and  begins  at  first  in  the  extremities,  and  afterwards  involves  the 
entire  body.  There  seems  to  be  an  accompanying  want  of  power,  for  he 
relaxes  his  hold  upon  any  object  he  may  grasp  when  his  attention  is  di- 
verted. His  morning  dram  involves  an  effort  worthy  of  a  better  cause. 
He  grasps  the  glass  with  both  hands,  fearing  that  he  may  spill  even  a 
single  drop  of  the  precious  liquid,  and  carries  it  carefully  to  his  mouth, 
clutching  the  rim  of  the  glass  between  his  teeth,  oftentimes  with  sufficient 
force  to  bite  out  a  piece.  The  lower  extremities  become  involved,  and 
the  patient  shuffles  along  in  a  clumsy  manner,  his  feet  being  scarcely 
lifted  from  the  ground.  His  dress  becomes  disorderly,  and  his  habits  are 
no  longer  characterized  by  neatness  and  tidiness.  His  facial  muscles 
lose  their  play,  and  his  countenance  wears  a  wonderfully  woebegone  and 
sorrowful  expression.  He  wanders  wretchedly  from  one  grog-shop  to  an- 
other ;  eats  sparingly,  and  rarely  ever,  uuless  his  worii-out  stomach  is 
stimulated  by  a  dram.  He  loses  flesh,  and  his  clothes  hang  to  his  with- 
ered limbs  like  the  vestment  of  a  scarecrow.  This  is  but  the  first  step  in 
the  advancing  disease.  Memory  becomes  weakened,  and  forgetting  even 
faces  and  names,  he  drops  one  by  one  his  old  friends,  and  sits  in  loneliness 
for  hours  at  a  time. 

The  mind  is  utterly  sapped,  and  he  is  reduced  to  a  state  of  dementia, 
l^umerous  grave  changes  occur  in  addition  to  these.  Speech  becomes  thick 
and  unintelligible.  In  the  early  stages  there  may  be  convulsions  or  attacks 
of  delirium  tremens ;  but  one  of  the  most  striking  and  serious  expressions  of 
the  disease  is  the  occurrence  of  paralysis;  and  there  may  be  hemiplegia  or 
paralysis  of  a  local  character,  the  third  nerve  becoming  implicated,  and 
ptosis  resulting.  The  subject  of  chronic  alcoholism  is  generally  anaesthetic, 
and  this  to  a  marked  degree.  Not  only  is  tactile  sensibility  impaired,  so 
that  he  is  unable  to  determine  the  nature  of  even  a  rough  object,  but  he  is 
uuafi'ected  by  extremes  of  temperature.  In  one  case  which  I  can  recall,  this 
was  illustrated  by  the  fact  that  in  sitting  before  the  fire  he  thrust  his  foot 
beneath  the  grate,  and  left  it  there  for  some  time  before  his  position  was 
discovered  by  a  member  of  the  family.  Hemi-an£ejthesia  ^  is  spoken  of  by 
some  writers,  but  it  is  an  extremely  rare  feature  of  the  disease,  and  is  pro- 
bably a  late  symptom  resulting  from  organic  changes  on  one  side  of  the 
brain.     An  anaesthetic  condition  of  the  cornea  has  been  alluded  to. 

Convulsive  seizures  of  difierent  kinds  are  occasional  evidences  of  the 
serious  effects  of  alcohol.  These  may  vary  from  simple  spasm  to  a  va- 
riety of  convulsion  which  closely  resembles  a  marked  epileptic  paroxysm. 
In  fact  the  diagnosis  is  oftentimes  very  difficult.     What  I  have  said. about 

^  Magnan  con.siders  that  organic  hemi-ansesthesia  and  general  paresis  are-  quite 
common  results  of  chronic  alcoholism,  op.  cit.,  p.  134. 
28 


434  CEREBRO-SPINAL    DISEASES. 

the  mental  condition  in  acute  alcoholism  may  be  now  applied.  The  hal- 
lucinations and  lighter  forms  of  sensory  and  mental  aberration  exist  at 
diffei'eut  stages,  but  towards  the  end  the  condition  is  one  of  dementia  of 
the  most  profound  character,  the  patient  being  completely  oblivious  of  the 
outside  world,  and  of  his  duties  to  society.  He  is  morally  irresponsible, 
and  the  crimes  he  may  commit  are  motiveless  and  dictated  only  by  a  dis- 
eased mind. 

Causes. — Chronic  alcoholism  follows  the  steady  use  of  large  quanti- 
ties of  alcoholic  liquors,  but  is  rarely  found  among  those  who  drink  wine 
or  malt  liquor.  The  French,  Italians,  and  Germans  are,  therefore,  seldom 
affected  in  their  own  countries,  especially  outside  of  the  large  cities,  where 
a  very  small  amount  of  ardent  spirits  is  taken.  In  England,  Scotland, 
Ireland,  and  America  the  case  is  different,  for  in  these  countries  there  is 
no  low-priced  light  beverage  which  takes  the  place  of  the  wines  and  beer 
of  the  European  Continent,  which  are  drunk  in  preference  to  water. 
"Without  entering  into  the  discussion  of  the  effects  of  alcohol  upon  other 
organs  of  the  body  than  those  of  the  nervous  system,  it  may  be  said  that 
the  condition  known  as  alcoholism  springs  from  a  protracted  use  of  large 
quantities  of  strong  liquor,  so  that  the  nervous  substance  is  deprived  of  its 
normal  nutrition,  the  blood  being  charged  with  effete  substances  which 
should  be  eliminated  by  the  kidneys,  lungs,  and  skin. 

Delirium  tremens  is  due  generally  to  the  direct  action  of  a  large  quan- 
tity of  alcohol,  which  produces  overwhelming  toxic  effects  ;  while  chronic 
alcoholism  implies  a  structural  degenei'ation  due  to  the  continued  action 
of  the  alcohol  itself,  and  to  the  vitiated  blood. 

Delirium  tremens  may  occur  either  from  a  sudden  cessation  of  indul- 
gence, or  in  the  midst  of  a  prolonged  debauch,  most  commonly,  however, 
the  latter.  In  some  persons  elimination  goes  on  so  perfectly  that  large 
quantities  of  liquor  may  be  taken  and  disposed  of  without  any  profound 
effect  upon  the  nervous  system  being  produced.  These  individuals  may 
drink  to  a  point  much  beyond  moderation,  and  still  suffer  no  marked  in- 
convenience, the  alcohol  seemingly  affecting  some  other  organ,  which  may 
be  either  the  liver  or  kidneys,  so  that  cirrhosis  or  degeneration  of  other 
kinds  may  take  the  place  of  the  cerebral  trouble  in  the  beginning. 

Males  are  much  more  often  affected  than  females,  as  the  statistics  of 
Magnau  show : — 

Acute  alcoholism  (D.  T.)      -j  ^„_.. 
Subacute     "  {J^l™ 

Chronic        "  / 1870 

11871 

This  fact  has  been  confirmed  by  statistics  collected  by  the  Health  De- 
partment of  New  York.  During  the  year  1873,  45  deaths  were  reported 
from  delirium  tremens,  but  four  of  whom  were  females.  It  is  probable 
that  there  were  many  more  cases  which  were  not  reported  as  such. 


M. 

F. 

35 

2 

42 

216 

51 

159 

47 

126 

11 

90 

14 

ALCOHOLISM.  435 

Women,  however,  though  not  so  subject  to  chronic  alcoholism  as  men, 
often  drink  to  excess,  and  not  rarely  develop  delirium  tremens.  This  bad 
habit  is  confined  chiefly  to  either  extreme  of  society — the  very  lowest  class, 
or  the  highest  in  the  social  scale.  Among  the  latter  the  amount  of  pri- 
vate dram-drinking  is  astonishing  ;  and  though  the  "  skeleton  in  the 
closet "  is  carefully  guarded  by  the  friends  of  the  patient,  it  is  by  no 
means  uncommon  for  the  physician  to  be  called  in  to  attend  cases  of  de- 
lirium tremens  in  high  life. 

Absinthe,  which  is  extensively  used  in  Paris,  and  is  beginning  to  be 
introduced  into  this  country,  produces  a  terrible  form  of  delirium  tremens, 
in  which  mania  is  a  marked  feature ;  and  a  form  of  epileptiform  attack  is 
also  quite  common. 

Alcoholism  is  much  more  often  observed  between  the  twentieth  and  the 
fiftieth  year,  and  is  very  rare  before  that  time. 

As  to  hereditary  predisposition  there  is  a  great  deal  to  be  said,  but 
when  we  attempt  its  consideration  we  depart  from  the  immediate  subject. 
Occupation  and  mental  influences  have  much  to  do  with  the  making  of 
drunkards  or  hard  drinkers.  Barkeepers,  and  individuals  exposed  to  se- 
vere weather,  are  commonly  addicted  to  drink  ;  the  one  either  feeling 
obliged  to  be  convivial  or  indulging  only  because  the  liquor  is  so  accessi- 
ble, and  the  other  because  he  "  needs  something  to  keep  out  the  cold." 
Mental  depression,  grief,  and  business  worry  are  interesting  in  their  social 
features,  but  do  not  strictly  come  within  the  scope  of  an  article  of  this 
character. 

Morbid  Anatomy  and  Pathology. — The  prolonged  use  of  alcohol 
is  followed  by  marked  changes  in  the  structure  of  the  nervous  substance. 
In  the  early  stages  there  may  be  found  appearances  which  are  ordinarily 
met  with  in  uncomplicated  cerebral  congestion,  viz.,  enlarged  vessels , 
injected  meninges,  and  effusions  of  serum.  These  may  vary  greatly  in 
their  extent  and  appearance,  and  may  be  associated  with  a  fatty  degenera- 
tion of  the  vascular  walls,  patches  of  softening,  or  even  little  foci  of  indu- 
ration. The  disease  leaves  its  traces  most  indelibly  stamped  as  meningeal 
thickening  and  opalescence,  and  perhaps  encysted  collections  of  blood, 
which  have  been  described  in  speaking  of  pachymeningitis.  The  sinuses 
are  engorged,  and  the  dura  mater  may  be  adherent  to  its  underlying  mem- 
branes ;  or  they,  in  turn,  may  be  in  such  close  contact  in  spots  with  the 
cortex  that  their  removal  necessitates  the  tearing  out  of  patches  of  super- 
ficial gray  substance.  The  convolutions  will  be  found  to  be  atrophied 
and  reduced  in  size,  and  the  ganglia  at  the  base  are  often  greatly  softened. 

Many  observers,  among  them  Carlisle  and  Percy,  have  found  alcohol  in 
the  fluids  in  the  ventricles.  Besides  these  intracranial  changes,  the  liver, 
kidneys,  and  stomach  present  appearances  with  which  all  pathologists  are 
familiar.  The  arteries  throughout  the  body  are  found  to  have  undergone 
atheromatous  degeneration,  and  this  is  seen  in  the  brain  to  a  very  decided 
degree.  As  to  the  condition  alluded  to  by  various  observers,  viz.,  th  e 
mechanical  change  exerted  directly  by  the  contact  of  alcohol  with  the  tis- 
sues, I  think  there  has  been  much  exaggeration.     The  sclerosis  so  often 


436  CEEEBRO-SPINAL    DISEASES. 

seen  is  much  more  probably  the  result  of  interstitial  inflammatory  change 
than  a  chemical  transformation. 

The  experiments  made  by  Anstie,^  Magnan,^  Percy,  Marcet,^  and 
Motet*  settle  with  great  certainty  the  pathological  processes  which  follow 
the  toxic  administration  of  alcohol.  Anstie  took  a  full-grown  dog  weigh- 
ing 10  lb.  4  ozs.,  and  injected  6  ozs.  of  mixed  alcohol  and  water  into  the 
itomach  at  1  P.  M.     No  food  had  been  taken  for  four  hours  previously. 

1.4  P.  M.  Auimal  obviously  affected;  staggers  in  walking,  and  fre- 
quently falls  down.  The  hind  quarters  are  weak,  and  skin  of  hind  limbs 
insensitive.     Resp.  24  ;  circulation,  140. 

1.6  P.  M.  Dog  lies  extended  on  the  floor  quite  drowsy,  but  capable  of 
being  roused  ;  fore-limbs  retain  slight  degree  of  voluntary  power.  Tongue 
protruded,  and  the  dog  "  slavers  "  still.  Skin  about  mouth  amesthetic  ; 
conjunctiva  sensitive. 

1.7.30, p.  M.  Animal  falls  on  its  side,  comatose  and  snoring.  Conjunc- 
tiva insensitive  with  other  parts.  Resp.  20  ;  circulation,  184,  tolerably 
strong.  Ano-genital  region  was  sensitive  to  painful  impressions.  Pupil 
strongly  contracted  at  first,  but  became  dilated  at  1.25,  little  sensitive  to 
light ;  antesthesia  remained  ;  eyes  still  insensitive ;  continuous  tremor  of 
hind-legs  began  and  continued  for  a  short  time.  Respiration  declined  in 
frequency,  and  became  gasping,  and  ceased  at  3.5  P.  M.,  two  hours  after 
the  ingestion  of  the  alcohol,  the  heart  beating  64  per  minute.  It  remained 
irritable  for  some  minutes  later.  Much  more  complete  and  earlier  coma 
followed  the  administration  of  larger  doses. 

The  continued  toxic  use  of  alcohol  produces  changes  not  only  upon  the 
nervous  system  directly,  but  secondarily  through  other  organs  which  are 
primarily  aSected.  A  large  quantity  of  alcohol  taken  into  the  system  in- 
duces pathological  changes  somewhat  after  the  following  manner :  A  certain 
portion,  quite  small  in  amount,  is  promptly  excreted,  and  maybe  detected 
in  the  breath,  urine,  bile,  and  sweat,  while  the  greater  proportion  remains  in 
the  blood,  greatly  altering  its  character  and  inducing  a  large  number  of 
interesting  changes.  Lallemand,  Marcet,  and  various  experimenters  have 
found  that  the  excretions  contained  much  pure  alcohol,  and  others  have 
detected,  by  the  chromic  acid  test,  traces  of  alcohol  forty-eight  hours  after- 
wards. Anstie  declares,  however,  that  but  the  merest  fraction  of  the 
amount  taken  is  eliminated  in  its  unchanged  form.  In  this  conclusion  he 
differs  from  the  authorities  I  have  quoted.  The  alcohol  remaining  in  the 
blood  is  partially  eliminated  in  its  decomposed  state  (carbonic  oxide  and 
water),  while  a  certain  quantity  remains.  The  internal  organs  are  con- 
gested, notably  the  liver,  kidneys,  and  lungs,  so  that  excretion  is  very 
slowly  performed,  and  the  urine  voided  is  scanty  in  amount,  devoid  of 
the  chlorides,  and  rich  in  urates.     The  blood  circulates  sluggishly,  and 

1  Stimulants  and  Narcotics,  p.  335  et  seq.  ''■  Op.  cit.,  p.  116. 

'  De  la  folic  causee  par  I'abus  des  boissons  alcooliques,  these  de  Paris,  1847. 
*  Considerations  generales  sur  I'alcoolisme,  et  plus  pardculierement  des  efl'ets  tox- 
iques  sur  I'liomme  par  la  liqueur  d'absintlie,  1859. 


I 


ALCOHOLISM. 


437 


contains  fat  and  sugar.  I  have  also  found  sugar  in  the  urine,  which  pro- 
bably resulted  from  irritation  of  the  medulla  as  well  as  certain  disturb- 
ances of  kidney  and  liver  function. 

The  abundance  of  carbonic  acid  requires  double  duty  upon  the  part  of 
the  lungs,  and  consequently  respiration  becomes  labored  and  quickened. 
The  natural  oxidation  of  the  blood  is  seriously  embarrassed,  and  elimina- 
tion is  retarded  most  seriously. 

The  nervous  system  of  course  suffers  from  this  change  in  its  badly  nour- 
ished state.  Degeneration  of  the  nervous  elements  follows,  and  interstitial 
thickening  and  medullary  metamorphoses  take  place,  so  that  the  loss  of 
function  is  very  great.  The  pneumogastric  being  implicated,  the  lungs 
and  other  organs  are  not  properly  innervated,  and  many  of  the  curious 
evidences  of  such  disorder  follow.  This  is  illustrated  by  the  tendency  to 
pneumonia  which  often  exists  as  a  feature  of  alcoholism. 

The  sympathetic  system  is  of  course  implicated.  The  actual  presence 
of  alcohol  is  attended  by  vaso-motor  paresis,  and  a  number  of  vascular 
changes  probably  follow.  It  might  be  well,  before  closing,  to  refer  to  a 
condition  of  the  cranial  bones  noted  by  Lancereaux  and  others,  A  hard- 
ening and  thickening  is  due  to  nutritive  changes,  which  Anstie  thinks  is 
not  a  true  hypertrophy,  as  the  original  texture  of  the  bone  is  lost. 

Prognosis. — A  table  prepared  by  Mr.  ISTeilson  from  the  Registrar- 
General's  report  shows  that  the  probable  duration  of  life  in  individuals 
who  have  reached  the  20th,  30th,  40th,  50th,  and  60th  years,  and  who 
have  been  either  temperate  or  intemperate,  is  about  the  following :  — 


Having  reached 

Has  an  average  chance 

But  the  intemperate  have  an  average  chance 

the  age 

of 

of  still  surviving 

of  surviving  only 

20 

44.21  years 

15.53  years,  or  35  per  ct.  of  the  duration  of 
life  of  the  general  population. 

30 

36.48     " 

13.80     "     "  38        " 

40 

28.70     " 

11.62     "     "  40 

50 

21.2-5     " 

10.86     "     "  51 

60 

14.28     " 

8.94     "     "  63        "            "             " 

This  applies  only  in  a  general  way  to  the  subject,  but  is  significant  in 
showing  how  greatly  the  alcoholic  habit  diminishes  the  patient's  chances. 
In  regard  to  the  prognosis  of  the  actual  attack,  there  is  rarely  any  rea- 
son to  fear  a  fatal  termination  unless  the  patient  has  had  a  number  of 
previous  ones.  Coma  and  convulsions  should  be  looked  upon  with  grave 
suspicion,  as  they  greatly  diminish  the  patient's  tendency  to  recovery. 
Chronic  alcoholism  is  more  unfavorable.  Should  the  patient  survive  his 
immediate  nervous  trouble,  it  is  very  likely  that  disease  of  some  other 
organ  will  carry  him  off.  Cirrhosis  is  the  most  common  of  these,  and  the 
patient's  mental  condition  may  be  for  some  time  aggravated  by  choles- 
tersemia.  Much  depends  upon  his  ability  to  reform  ;  and  no  assurance 
can  be  given  that  he  will  recover  until  this  is  accomplished. 

Diagnosis. — The  only  diseases  for  which  alcoholism  maybe  mistaken 


438  CEREBRO-SPINAL    DISEASES. 

are:  1.   General  paresis;   2.  Sclerosis,  and  paralysis  agitans;  3.  Soften- 
ing ;  4.  Dementia. 

1.  General  paralysis  differs  from  delirium  tremens  in  the  fact  that  in 
the  former  the  delusions  are  always  pleasurable  and  exalted.  The  general 
paralytic  is  the  king,  the  capitalist,  the  ruler  of  the  universe ;  the  alco- 
holic patient  is  depressed,  dejected,  and  sad.  These  differences,  taken  into 
consideration  with  the  fact  that  the  patient  suffers  from  anorexia,  that  his 
face  is  flushed,  and  the  conjunctivae  red,  ought  to  settle  the  real  nature  of 
the  trouble.  Anstie^  alludes  to  the  presence  of  acne  as  a  pathognomonic 
sign.  Chronic  alcoholism  may  very  closely  resemble  general  paresis, 
but  there  is  more  proper  dementia  in  the  latter, 

2.  Sclerosis  and  paralysis  agitans  are  sometimes  confounded  with  chro- 
nic alcoholism  when  there  is  much  disturbance  of  co-ordination.  The 
tremor  and  inco-ordiuation  are  much  greater  during  voluntary  action, 
however,  in  the  first  conditions,  and  there  is  rarely  any  mental  disturb- 
ance in  either. 

3.  Softening  resembles  chronic  alcoholism,  but  the  paralysis  and 
speech  disturbance  ai'e  much  more  pronounced,  there  generally  being 
aphasia,  and  the  headache  besides  is  quite  different  from  that  of  alcohol- 
ism. 

4.  Senile  dementia  may  make  the  diagnosis  somewhat  difficult.  The 
previous  history  of  the  patient,  however,  will  generally  clear  away  any 
doubts  that  may  arise. 

Treatment. — The  physician's  first  attempt  should  be  to  prevent  the 
patient  from  further  indulging  his  de^jraved  appetite.  How  this  is  to  be 
accomplished  depends  very  much  upon  his  surroundings,  temperament, 
and  condition.  If  the  attack  arises  during  a  debauch,  I  prefer  to  cut  off 
at  once  the  supply  of  alcohol,  unless  he  is  utterly  prostrated.  If  the  at- 
tack occurs  after  cessation,  we  may  then  give  small  quantities  of  stimu- 
lants, and  "  taper  off."  Should  he  be  irritable  and  excited,  immediate 
recourse  to  sedatives  and  hypnotics  should  be  had.  I  have  great  faith  in 
the  bromides,  lupulin,  or  simple  remedies  of  this  class.  Fifteen  or  twenty 
grains  of  the  bromide  of  calcium,  given  in  a  drachm  of  the  tr.  lupulin 
twice  or  three  times  a  day,  is  often  sufficient  to  quiet  the  nervous  state. 
A  good  cathartic  which  shall  increase  the  action  of  the  liver,  and  hasten 
elimination  of  the  alcohol,  is  an  early  form  of  treatment  which  is  gene- 
rally recommended.  Should  the  insomnia  be  troublesome  or  the  delirium 
violent,  we  may  administer  either  the  bromides,  or  the  mono-bromide  of 
camphor,  which  I  make  the  claim  of  being  the  first  to  use  for 
this  purpose.  It  may  be  given  in  pilular  form,  made  up  with  confection 
of  roses,  in  doses  of  five  grains  every  hour  until  sleep  is  produced.  The 
bromides  of  calcium  or  sodium  in  thirty  grain  doses  every  two  hours 
sometimes  succeed,  or,  better  still,  they  may  be  combined  with  chloral 
hydrate,  so  that  the  patient  shall  take  fifteen  grains  of  each  every  two 
hours  until  the  excitement  subsides.     Cannabis  indica  has  enjoyed  great 

^  Article  on  Alcoholism,  Keynolds's  System,  American  Edition,  vol.  i.  p.  677. 


I 


NICOTINISM.  439 

popularity  iu  the  treatment  of  this  trouble,  and  should  be  given  in  doses 
of  from  one-half  to  one  grain  of  the  extract.  Should  the  maniacal  ex- 
citement be  intense,  I  know  of  no  better  remedy  than  morphine  adminis- 
tered hypodermically,  but  not  by  the  mouth,  as  it  may  lie  unabsorbed  for 
some  time  with  producing  any  effect ;  and  the  physician  may  be  tempted 
to  give  still  more  than  the  ordinary  dose,  when  to  his  surprise  absorption 
takes  place,  and  its  cumulative  action  follows.  Digitalis  has  been  recom- 
mended in  large  doses,  and  Anstie  preferred  the  powder  because  the  alco- 
hol of  the  tincture  interfered  with  the  proper  action  of  the  drug.  I  am 
inclined  to  think  that  the  application  of  digitalis  stupes  to  the  lumbar 
region  and  the  abdomen  favors  kidney  action,  and  does  more  good  than 
when  the  medicine  is  given  by  the  mouth. 

It  is  of  importance  that  the  action  of  the  skin  and  bowels  should  be 
increased.  For  the  first  object,  small  doses  of  tartar  emetic  assist  the 
emunctory  action  of  the  skin,  while  the  compound  jalap  powder  induces 
copious  and  watery  discharges  from  the  bowels.  Cold  to  the  head,  either 
by  ice-bags  or  cloths  wet  with  ice-water,  blisters  to  the  calves,  and  local 
abstraction  of  blood  may  be  resorted  to  in  violent  cases.  As  to  food  : 
when  the  worn-out  stomach  refuses  all  ordinary  articles  of  diet,  it  will 
rarely  reject  iced  milk,  which  may  be  given  in  all  cases.  After  a  while 
soups,  nutritious  broths,  or  bouillon  made  from  beef,  or  Valentine's  beef 
juice,  or  Borden's  extract  of  beef,  either  of  which  is  preferable  to  the 
Liebig  extract  on  account  of  the  nauseous  taste  of  the  latter,  may  be 
given  in  liberal  quantities.  Small  doses  of  carbonic  acid,  seltzer,  or 
Apollinaris  water,  or  coflfee  may  be  administered  before  eating,  and  gently 
stimulate  the  stomach,  in  this  respect  taking  the  place  of  the  drams. 

The  patient's  nausea  may  be  corrected  by  the  aromatic  spirits  of  ammo- 
nia, or  bismuth  and  morphine,  the  latter  in  very  small  doses. 

In  chronic  alcoholism  the  aim  of  the  physician  should  be  to  restore  the 
normal  action  of  the  viscera  ;  to  stop  the  supply  of  drink ;  and  to  freely 
administer  the  various  preparations  of  iron,  quinine,  and  phosphoric  acid, 
as  well  as  cod-liver  oil.  I  have  found  that  dialyzed  iron  is  well  borne  by 
the  irritable  stomach,  does  not  constipate,and  is  therefore  an  excellent 
remedy.     This  may  be  given  with  tr.  digitalis  and  tr.  nux  vomica. 

NICOTINISM. 

"When  the  nervous  system  is  subjected  to  the  influence  of  tobacco  in  ex- 
cessive quantities  a  train  of  symptoms  may  be  manifested  indicating  a  con- 
dition of  affairs  that  may  ultimately  assume  a  serious  character.  While 
I  believe  tobacco  to  be  one  of  the  most  valuable  articles  of  comfort  we 
possess,  I  every  day  am  made  aware  that  in  an  insidious  way  it  produces 
nervous  disorders  which  are  sometimes  quite  as  formidable  as  those  caused 
by  alcohol.  I  have  found  in  more  than  one  case  of  general  paresis  that 
the  immoderate  use  of  tobacco,  had,  in  those  of  unstable  nervous  tem- 
perament, all  to  do  with  the  development  of  the  disease.  I  have  no  in- 
tention, however,  of  entering  into  the  discussion  of  its  general  bearings  in 
relation  to  public  health  and  the  morals  of  the  community,  for  these  sub- 


440  CEREBRO-SPINAL    DISEASES. 

jects  have  been  frequently  discussed  by  popular  reformers— and  not 
always  temperately  or  truthfully — but  I  will  briefly  call  attention  to  the 
nervous  expression  of  chronic  tobacco  poisoning. 

Symptoms. — The  question  of  tolerance,  in  connection  with  physical 
development;  the  effect  of  the  constant  use  of  tobacco  upon  the  nervous 
individual — the  possessor  of  the  insane  neurosis,  perhaps — enter  largely 
into  the  genesis  of  nervous  symptoms. 

In  persons  of  full  habit,  of  phlegmatic  temperament,  and  fat-making 
tendency  tobacco  may  be  used  in  considerable  quantities  and  quite  con- 
stantly without  other  than  trifling  effect,  and  in  the  rheumatic  diathesis 
it  is  positively  beneficial.  In  the  spare,  nervous  individual  the  case  is 
different,  and  the  careless  and  continuous  use  of  tobacco  often  produces  a 
train  of  motorial  and  sensorial  symptoms  of  varying  grades  of  gravity. 
Both  the  voluntary  and  involuntary  muscles  may  be  affected,  and  atonic 
action  of  the  unstriped  muscular  fibre  result  in  a  variety  of  cardiac  and 
digestive  disturbances. 

The  action  upon  the  heart  is  decided,  there  being  great  feebleness  and 
inequality  of  the  pulse,  and  as  the  brain  becomes  the  seat  of  chronic 
anaemia  we  find  dizziness,  headache  and  melancholia,  besides  a  variety  of 
light  mental  troubles.  The  muscular  tissue  of  the  stomach,  intestines 
and  lower  bowel  are  enfeebled  so  that  slow  digestion  and  loose  evacua- 
tions are  consequent. 

The  production  of  general  muscular  weakness  is  a  very  conspicuous 
manifestation  of  the  depressed  tone  of  the  nerve  centres.  These  may  be  ex- 
pressed either  in  tremor,  slight  paresis,  or  an  epileptoid  condition  ;  the 
tremor,  however,  is  the  most  familiar  of  all  disorders  of  motility. 

It  may  be  unilateral,  but  is  usually  found  on  both  sides,  the  upper  ex- 
tremities being  more  often  its  seat  than  the  lower,  and  like  the  same  mo- 
torial disorder  seen  in  alcoholism,  and  among  opium  eaters  it  may  be 
overcome  for  the  time  by  recourse  to  the  cause.  It  is  essentially  the 
tremor  of  debility,  and  has  no  very  regular  character.  If  the  smoker  ex- 
tends his  hand  so  that  it  is  in  a  somewhat  constrained  position,  he  will 
notice  that  some  fingers  are  more  agitated  tha  n  others,  notably  the  second 
and  third. 

An  advanced  grade  of  motor  feebleness  is  expressed  in  paresis,  but 
rarely  by  paralysis,  so  far  as  complete  and  diffused  anaesthesia  is  con- 
cerned. Erb,  under  the  head  of  toxic  spinal  paralysis,  speaks  of  the 
influence  of  tobacco  in  its  production,  and  says  that  it  causes  lasting 
paralysis  when  the  toxic  action  is  slow  and  repeated,  and  much  more 
rapidly  than  when  acute.  There  is  usually  diminution  of  electro-muscular 
contractility.  Various  other  disorders  of  motility  are  shown  in  local 
spasms,  and  among  them  are  painless  facial  twitchings  and  blepharo- 
spasm, which  may  be  very  distressing  ;  spasms  of  the  limbs  and  starting 
during  sleep.  Not  a  small  number  of  cases  of  chronic  tobacco  poisoning, 
as  I  have  said,  end  in  the  direct  production  of  serious  organic  disease 
of  the  brain,  and  symptoms  in  many  respects  similar  to  those  of  cerebral 
softening  or  general  paresis  will  be  expressed.     The  pupil  presents  no 


NICOTINISM.  441 

constant  appearance  that  may  be  considered  important.  Some  authors, 
among  them  Taylor,  and  Woodman  and  Tidy  hold  that  it  is  dilated  in 
acute  poisoning,  while  Pereira  and  Bartholow,  say  contracted,  but  in 
chronic  nicotinism  it  is  usually  dilated.  The  urine  is  copious  and  loaded 
with  earthy  phosphates.  Various  dyssesthesia  are  common  in  chronic 
nicotinism.  The  patienfe  calls  attention  to  tinnitus,  "  tightness  about  the 
throat,"  "  pains  beneath  the  ears,"  as  well  as  intercostal  pains,  coldness 
of  the  feet,  crawling  sensations,  and  a  sense  of  feebleness,  especially  in 
the  morning. 

Amaurosis  is  one  of  the  indications  of  anaesthesia.  ^Drysdale  reported 
the  cases  of  two  young  men  who  became  amaurotic  from  the  continued 
use  of  tobacco,  in  one  case  the  man  taking  but  half  an  ounce  of  tobacco 
a  day.  ^  Masselon  in  an  admirable  thesis  refers  to  the  production  of  color 
blindness,  one  of  his  patients  being  unable  to  tell  a  piece  of  silver  from 
a  piece  of  gold,  and  in  all  cases  the  patients  seemed  to  lose  the  faculty  of 
distinguishing  yellow  and  red  from  other  colors. 

^Webster,  in  a  very  careful  paper,  has  called  attention  to  the  amblyo- 
pia produced  by  tobacco,  and  fully  believes  that  tobacco  alone  may  give 
rise  to  this  ocular  trouble.  In  seven  out  of  twenty  cases  he  found  inci- 
pient atrophy  of  the  optic  nerve.  In  18  of  Webster's  cases  alcohol  and 
tobacco  were  used  to  excess,  and  in  one  case  tobacco  was  used  excessively 
from  ten  to  fifteen  years,  and  alcohol  moderately,  and  an' occasional  glass 
of  gin  was  taken.  In  one  case  in  which  the  amblyopia  seemed  to  be 
wholly  due  to  the  abuse  of  tobacco,  the  vision  rose  from  t^tt  to  70  in 
each  eye  when  the  patient  abstained  from  its  use,  and  received  appropri- 
ate treatment.  Dr.  Ely  takes  a  more  conservative  view  of  tobacco 
j)oisoning  as  a  cause  of  amblyopia. 

Cutaneous  hyperathesia  or  anaesthesia  are  by  no  means  rare  symptoms 
of  chronic  tobacco  poisoning.  I  have  in  patients  repeatedly  found  anaes- 
thesia of  the  lips  and  tongue,  and  in  one  subject  smell  was  abolished,  and 
not  restored  until  the  patient  was  subjected  to  a  course  of  strychnia. 
Tactile  sense  is  sometimes  blunted,  and  especially  is  such  the  case  in  the 
tips  of  the  fingers.  Neuralgic  pains  are  by  no  means  uncommon,  and  are 
perhaps  among  the  early  sensory  troubles.  These  pains  may  counterfeit 
those  of  early  locomotor  ataxia,  and  create  great  misery.  In  other  cases 
there  may  be  cardiac  neuralgia,  resembling  in  many  respects  the  pain  of 
angina  pectoris.  So  grave  is  this  symptom  that  even  medical  men  who 
smoke  to  excess  often  believe  themselves  to  be  the  subjects  of  this  affec- 
tion. Vague  muscular  pains,  shortness  of  heart,  and  fatigue  after  slight 
exertion  all  come  in  for  a  share  of  our  attention. 

The  mental  expressions  of  nicotinism  are  exceedingly  variable,  and 
may  consist  in  the  beginning  simply  of  a  change  in  the  temper  and  dis- 
position, evinced  by  irritability,  and  accompanied  by  loss  of  memory, 
irresolution  and  hypochondriasis;  or  in  a  graver  form  we  may  find  actual 

1  British  Medical  Jonrnal,  Sept.  5,  1874.  2  These  de  Paris,  1872. 

3  Medical  Eecord,  Dec  11,  1880. 


442  CEREBRO-SPINAL    DISEASES. 

symptoms  of  insanity,  illusions,  hallucinations  and  delusions  either  insane 
or  otherwise,  attacks  of  extreme  excitement  amounting  to  mania,  or  per- 
haps mania  itself. 

^Backnill  and  Take  speak  of  tobacco  poisoning  in  the  causation  of 
insanity,  and  '  Kirkbride  reported  four  cases  of  insanity  due  to  tobacco. 
^Skac  reports  a  case  of  mania  produced  by  tobacco,  and  Continental 
literature  contains  other  observations. 

The  skin  is  usually  muddy  in  color,  and  the  mucous  membrane  o    f  e 
tongue  of  an  excessive  smoker  presents,  according  to  some  observers,  the 
appearance  as  if  it  had  been  brushed  over  with  nitrate  of  silver. 

Causes. — Tobacco,  when  used  to  excess,  does  far  more  harm  in  some 
ways  than  others ;  and  the  purity  of  the  substance  and  the  method  of  its 
consumption  greatly  influence  the  troubles  that  may  follow.  *  Anstie 
says :  "  There  are  a  few  whom  no  amount  of  care  and  skill  exercised  in 
taking  the  tobacco,  nor  any  moderation  in  the  dose  used,  can  save  from 
unmistakable  poisoning  whenever  they  indulge  in  it.  These  cases  are 
rare,  and  they  should  be  carefully  separated  from  the  evil  results  which 
are  produced  by  mere  unskillfulness  in  smoking."  Chronic  poisoning 
arises  from  certain  bad  habits,  and  these  may  be  enumerated  as :  1. 
Smoking  when  the  stomach  is  empty.  2.  Using  several  cigars  in  succes- 
sion. 3.  Inhaling  the  smoke  of  cigars  or  cigarettes.  4.  Smoking  only  a 
pipe  in  which  the  nicotine  has  collected.  5.  Swallowing  the  saliva. 
Among  smokers  it  is  found  that  the  nervous  effects  are  more  easily  pro- 
duced in  the  early  part  of  the  day. 

It  is  difiicult  to  say  just  how  much  tobacco  is  harmful.  In  a  case  re- 
ported by  ^Gmelin,  seventeen  or  eighteen  pipes  were  smoked  in  quick 
succession  by  two  men  with  fatal  results. 

The  use  of  snuff  by  women  in  the  manner  known  as  "  dipping,"  is  hap- 
pily becoming  rare  in  this  country.  I  have  seen  several  examples  of  this 
kind  leading  to  chronic  poisoning.  A  stick,  tooth-brush,  or  some  such 
article,  is  dipped  in  fine  snuff,  and  the  gums  and  inside  of  the  mouth  are 
rubbed  therewith.  The  toxic  effects  of  tobacco  are  produced  in  a  short 
space  of  time  and  are  said  to  be  pleasurable.  I  have  found  this  custom  to 
be  prevalent  among  prostitutes,  but  it  is  by  no  means  confined  to  them. 
In  Ihe  case  of  a  lady  of  refinement  and  social  position,  I  found  that  a 
peculiar  train  of  obstinate  nervous  symptoms  were  due  to  "  snuff  dipping," 
and  search  disclosed  small  parcels  of  snuft'  under  her  pillow  and  beneath 
the  mattrass  of  her  bed. 

Cigarette-smoking,  which  has  increased  to  an  incredible  extent  of  late 
in  this  country,  is  much  more  apt  to  give  rise  to  nervous  symptoms,  be- 
cause of  the  tendency  to  almost  constant  indulgence,  and  the  inhalation  of 
the  smoke. 

1  Manual  of  Psychological  Medicine,  p.  100. 

2  Annual  Report  of  Philadelphia  Hospital  for  the  Insane,  1880. 

3  Ed.  Med.  Journal,  Jan.,  1856. 

*  Stimulants  and  Narcotics,  p.  138. 

5  Eeported  by  Woodman  and  Tidy,  p.  379. 


NICOTINISM.  443 

Pathology. — According  to  ^  Anstie,  tobacco  is  a  narcotic-stimulant, 
and  he  classes  it  with  tea  and  coffee.  The  poisonous  effects,  as  agreed  by 
most  authors,  are  excited  in  l^wo  ways :  1st.  In  interfering  with  the  pul- 
monary circulation,  retention  of  carbonic  acid  gas,  and  blood-poisoning. 
2.  A  direct  influence  from  the  nervous  tissue  itself.  The  motor-nerves 
seem  to  suffer  abasement  of  function,  though  the  muscular  irritability  is 
not  disturbed. 

There  seems  to  be  some  doubt  as  to  the  poisonous  agent  in  tobacco. 
Vogel  says  that  the  toxic  properties  of  tobacco-smoke  are  due  to  the  pre- 
sence of  sulphide  and  cyanide  of  ammonia.  ^Eulenburg  could  not  find  a 
trace  of  nicotin  (Woodman  and  Tidy),  but  he  and  Vohl  believed  the  poi- 
sonous substance  to  be  pyridin  (C  5  H  5  N.)  and  parvolin  (C  9  H 13  N.) 
^  Huebel,  however,  has  found  the  amount  of  nicotin  in  one  cigar  sufficient 
to  produce  convulsions  and  death  in  a  frog. 

There  is  undoubtedly  in  tobacco-smoke  a  certain  amount  of  nicotin  and 
other  alkaloids  in  combination  with  alkaline  bases.  In  gouty  subjects, 
therefore,  the  use  of  tobacco  cannot  fail  to  be  beneficial,  when  smoked  in 
moderation. 

In  small  quantities  tobacco  slightly  exhilarates  and  increases  the  action 
of  the  heart,  and  one  cigar  may  effect  a  prompt  increase  of  thirty  or 
forty  pulse-beats — a  secondary  depression  follows,  however. 

^Headland  ascribes  the  comparatively  light  narcotic  effect  of  tobacco  to 
its  prompt  elimination  by  the  kidneys,  and  says  :  "  It  is  only  not  a  poi- 
son because  slowly  taken  into  the  system  in  small  amounts  and  eliminated 
pari  passu."  In  those  individuals  in  whom,  through  disease  of  the  ex- 
creting organs,  the  poisonous  elements  are  not  promptly  removed,  the 
production  of  nicotinism  is  much  more  prompt.  The  occurrence  of  ver- 
tigo is  probably  often  due  to  a  cumulative  efiect  which  occasions  cardiac 
weakness.  The  cerebral  effects  of  prolonged  nicotinism  are  occasioned 
by  the  continued  malnutrition  of  the  brain  tissue. 

Prognosis  and  Treatment. — Nearly  all  the  alarming  symptoms 
can  be  immediately  moderated  or  cut  short  by  prompt  discontinuance, 
and  recourse  to  nux  vomica  or  its  alkaloid.  The  analysis  of  tobacco  by 
^Schlossing  and  others,  with  regard  to  the  quantity  of  nicotine  has  some 
bearing  upon  the  evil  effects  attending  its  immediate  use. 

In  100  parts  of  Virginia  tobacco  Schlossing  found  6.87  parts  of  nicotine 
In  the  same  quantity  of  Kentucky  tobacco  there  were  6.09  ;  in  French 
tobacco,  4.94 — 7  ;  Maryland,  2.29  ;  Havanna,  less  than  2.  In  dry  snuff 
there  is  2  per  cent. ;  in  moist,  1.3. 

Those  who  use  tobacco  are  rarely  inclined  to  acknowledge  its  bad  eflects 
but  to  attribute  them  to  other  causes  ;  but,  as  Taylor  says,  "  The  argument 
that  cases  cannot  be  adduced  to  show  direct  injury  to  health  proves  too  much 
— for  a  similar  observation  may  be  made  of  the  habit  of  opium-eating." 

^  Stimulants  and  Narcotics,  p.  100. 

2  Viertljahrschrift  f.  Ger.  Med.  N.  F.  xiv.,  p.  249,  and  Woodman  &  Tidy,  p.  379. 

3  Centralblatt,  Oct.  5, 1872.    *  Adion  of  medicines,  p.  269.    ^  Quoted  by  Taylor,  p.  771- 


444  CEREBRO-SPINAL    DISEASES. 

For  the  person  who  presents  decided  nervous  symptoms  traceable  to 
tobacco,  no  better  treatment  can  be  suggested  than  the  continuous  use  of 
a  tonic  containing  iron,  quinine,  and  strychnine, — such,  perhaps,  as  the 
following : 

R — Strychnine  Sulphas, gr.  i. 

Quinice  Sulphas 5'' 

Tr.  Ferri.  Chloridi 5^"- 

Acidi Phosp.  dil.     )         ^-.. 

Syr.  Limonis J  '-' 

Sig. : — Oue  teaspoonful  in  water  thrice  daily. 
Strychnine  alone,  in  small,  repeated  doses,  or  perhaps  combined  with 
digitalis,  is  useful.     In  amblyopia  many  authors,  among  them  Webster, 
recommend  the  hypodermic  use  of  strychnine.   From  1-60  to  1-24  gr.  may 
be  given  at  a  dose. 

HYDROPHOBIA. 

Synonyms. — Rabies  canina ;  Paraphobia;  Lyssaphobia  (?). 

The  name  adopted  to  express  that  form  of  nervous  trouble  which  some- 
times follows  the  bite  of  a  rabid  animal  is  an  evident  misnomer,  as  the 
definition  of  the  term  signifies  "  a  dread  of  water."  As  this  is  but  one 
symptom,  and  by  no  means  a  constant  one,  the  first  synonym  is  much 
more  expressive  and  appropriate,  and  is  in  every  way  preferable  to  that  in 
general  use. 

Symptoms. — 1-  Period  of  Incubation. — After  the  receipt  of  the  bite, 
which  may  produce  an  extensive  wound,  or,  as  is  the  case  sometimes,  an 
insignificant  scratch,  a  period  of  time  extending  from  a  few  months  to 
several  years  may  elapse  before  the  appearance  of  the  second  stage.  The 
wound  may  heal  by  first  intention,  giving  rise  to  no  inconvenience,  or 
there  may  be  redness  and  neuralgic  pain.  A  history  of  this  kind  is  usu- 
ally given  by  the  patient,  and  is  based  upon  an  exaggerated  statement  of 
the  actual  facts,  which  arises  from  a  disordered  imagination,  while  his  story 
of  the  accident  and  of  his  subsequent  symptoms  is  tinctured  with  a  deci- 
ded flavor  of  romance.  Nervous  derangement  dependent  upon  fear,  di- 
gestive disorders,  mental  worry,  and  others  of  the  same  category,  generally 
characterize  this  first  stage. 

2.  Period  of  Invasion. — At  the  end  of  the  period  of  incubation,  the 
first  alarming  symptoms  noticed  are  those  connected  with  the  cicatrix, 
which  becomes  painful  aad  tender,  and  at  the  same  time  there  are  pains 
which  dart  along  the  nerves  in  the  vicinity.  There  are  next  generally 
headache  and  a  sense  of  epigastric  oppression,  with  constipation,  broken 
sleep,  and  a  feeling  of  general  discomfort.  At  the  end  of  two  or  three 
days,  during  which  the  patient  suffers  intensely,  we  may  expect  the  appear- 
ance of  the  next  stage. 

3.  The  Period  of  Development. — With  aggravation  of  the  symptoms 
just  enumerated,  we  find  added  thereto  a  sense  of  constriction  about  the 
throat,  irregular  and  quickened  respiration,  rigidity  of  the  muscles  of  the 
neck,  discomfort  in  deglutition,  and  spasms,  which  begin  in  the  muscles  of 


HYDROPHOBIA.  445 

the  throat  and  back  of  the  neck,  and  gradually  invade  those  of  the  back. 
The  spasms  give  rise  to  much  pain,  which  is  sometimes  spinal  and  at  others 
muscular.  The  patient  is  at  this  stage  delirious  and  flighty,  and  gene- 
rally has  delusions  in  which  dogs  play  an  important  part.  The  difficulty 
of  swallowing,  which  next  follows,  is  not  so  great  when  solids  are  taken. 
Fluids,  on  the  contrary,  seem  to  produce  an  aggravation  of  the  spasms, 
and  the  mere  sound  of  splashing  or  trickling  water  will  excite  a  convulsive 
seizure.  To  add  to  the  sufferings  of  the  patient,  there  is  excessive  thirst, 
which  is  very  distressing.  His  face  becomes  dusky,  and  his  eyes  promi- 
nent and  wild.  He  tosses  from  side  to  side  if  placed  in  bed,  the  saliva 
running  from  the  angle  of  the  mouth  in  a  viscid  stream.  Towards  the 
end  of  the  disease  this  secretion  becomes  thicker  and  mixed  with  mucus, 
and  it  collects  in  the  trachea  and  bronchi.  These  symptoms  may  last 
two  or  three  days,  while  in  the  meantime  the  reflex  excitability  becomes 
so  great  as  to  precipitate  a  convulsion  under  the  least  stimulus.  The  pulse 
is  rapid,  the  headache  more  severe,  the  air-passages  become  filled,  and 
respiration  is  greatly  interfered  with.  The  convulsions  are  readily  pro- 
duced by  blowing  upon  the  patient,  or  by  jarring  him,  or  even  by  slam- 
ming the  door.  At  this  stage  he  becomes  partially  unconscious,  is  quite 
delirious,  and  very  much  agitated.  Previous  to  death  there  is  a  marked 
rise  in  the  temperature,  and  in  one  case  I  saw,  the  history  of  which  I  shall 
presently  relate,  the  temperature  rose  to  103°,  and  I  believe  there  was  even 
a  subsequent  rise. 

Death  occurs  in  two  or  three  days  in  most  cases,  but  it  may  be  delayed 
a  day  or  two  longer.  Incontinence  of  urine  and  feces  precedes  the  end ; 
the  immediate  cause  of  death  being  asphyxia  from  spasmodic  stenosis  of 
the  larynx,  or  obstruction  of  the  air-passages  by  mucus.  I  had  the 
privilege  of  seeing  one  case  at  the  request  of  Dr.  Augustus  Viele,  of  this 
city,  which  was  subsequently  reported  by  Dr.  Hadden.^ 

Through  the  courtesy  of  Dr.  Hadden  and  Deputy  Coroner  Leo,  I  was 
also  enabled  to  observe  the  post-mortem  appearances  of  the  brain  and 
cord.  Dr.  Hadden  describes  the  case  so  minutely  that  I  shall  mainly  use 
his  own  words. 

"  On  the  24th  ultimo,  at  8.30  P.  M.,  I  was  called  to  attend  a  young  man 
named  Wm.  McCormick,  residing  at  No.  309  East  51st  Street,  a  native  of 
this  city,  aged  26  years,  athletic  in  appearance,  of  usually  good  health, 
nervous  temperament,  and  of  moderately  temperate  habits ;  by  occupation 
a  driver  of  an  express-wagon.  He  was  in  bed,  complaining  of  nervous- 
ness, soreness  in  his  nock  and  throat,  strange  feelings  of  tightness  around 
his  chest.  His  countenance  was  anxious,  pupils  of  his  eyes  were  dilated, 
and  his  general  appearance  was  like  one  who  was  in  fear  of  impending 
danger,  and  not  in  extreme  pain.  He  told  me  that  his  throat  was  so  sore 
that  he  could  not  swallow  anything — not  even  water.  This,  he  thought, 
was  due  to  some  simple  medicine  he  had  taken,  and  not  to  any  serious 
ailment.     I  noticed  his  throat  was  not  swollen  on  the  outside,  and  that  his 

^  Journal  of  Psychological  Medicine,  May,  1870,  p.  80. 


446  CEREBRO-SPINAL    DISEASES. 

voice  was  whining,  and  unlike  a  person  suffering  from  any  ordinary  sore- 
ness within.     I,  however,  examined  his  throat  within,  but  found  nothing 
to  account  for  this  difficulty  ;  it  was  perfectly  healthy  in  appearance. 
His  pulse,  respiration,  and  temperature  were  normal,  excepting  an  occa- 
sional sigh.     I  observed,  also,  a  little  disposition  to  hack  and  spit,  but  in 
no  way  troublesome.     He  complained  also  of  thirst,  but  said  he  could  not 
drink,  he  knew,  for  the  very  sight  of  w'ater  made  him  shudder.     I  told 
him  his  throat  was  not  sore,  and   urged  him  to  try.     He  assented,  and 
water  was  accordingly  brought,  which,  at  sight,  caused  a  violent  spasm. 
He  threw  himself  around  in  the  bed,  forward  and  backw^ard,  and  told  the 
party  to  take  it  away  at  once,  as  it  would  kill  him.     He  immediately  af- 
terwards called  for  the  goblet,  and  said  he  was  very  thirsty  and  must 
drink,  seized  it,  and  with  a  violent  effort  succeeded  in  taking  a  single 
swallow,  which  was  followed  by  a  severe  convulsive  shudder  and  contrac- 
tion of  the  muscles  of  the  neck  and  chest."     Dr.  Hadden ascertained  the 
fact  that  he  had  been  bitten  by  a  dog,  and  then  inquired  about  the  symp- 
toms antecedent  to  his  visit.     "  Wednesday  and  the  two  preceding  days 
he  was  complaiuing  of  general  lassitude  and  nervousness  ;  had  not  been 
able  to  sleep  at  night ;  was  thirsty,  and  had  drunk  a  great  deal  of  water; 
had  eaten  but  little ;  appetite  very  poor,  and  on  Wednesday  afternoon  he 
seemed  to  be  growing  worse.     He  went  out  upon  the  street,  but  soon  re- 
turned, saying  that  it  was  very  chilly,  and  he  could  not  stand  thQiair  at 
all.     While  taking  a  cup  of  tea  at  6  P.  M.  the  same  evening,  he  first 
showed  signs  of  difficulty  in  swallowing.     Shortly  afterwards,  as  he  was 
going  to  the  kitchen,  he  was  met  by  a  draught  of  cold  air,  which  so  stag- 
gered him  that  he  nearly  fell ;  he  then  went  to  bed,  where  I  found  him. 
After  giving  the  necessary  caution  to  the  family,  I  ordered  fifteen  grains 
of  bromide  of  potassium  to  be  given  every  hour.     I  left,  and  returned  at 
10.30  p.  M.  .  .  .  Found  him  in  about  the  same  condition  I  had  left  him, 
only  his  pulse  was  irregular,  and  his  spasms  more  frequent.     The  saliva 
was  a  little  more  troublesome,  and  he  also  could  not  swallow  without  great 
difficulty.     I  was  called  again  at  2.30  A.  M.,  the  messenger  stating  that 
the  patient  had  become  very  violent,  and  that  they  were  unable  to  restrain 
him.     I  went  immediately.  .  .  .  Found  him  in  a  frightful  state  of  excite- 
ment; had  broken  down  the  bed,  and  was  struggling  with  his  attendants 
to  get  at  liberty.     He  was  shouting  and  crying  out  to  them  to  let  him  go, 
and  called  for  water,  which,  when  brought,  he  could  not  drink.     His  mind 
was  clear,  and  he  knew  all  those  around  him  ;  was  spitting  a  viscid  saliva, 
but  was  cai'eful  not  to  spit  upon  any  one,  not  even  on  his  clothes.     It  was 
so  abundant  that  his  attendants  were  obliged  to  wipe  it  from  his  lips.    Dr. 
Leavitt  and  myself,  after  viewing  the  case  in  all  its  aspects,  concluded  to 
inject  in  the  tissues  of  the  leg  half  a  grain  of  morphine  and  one-sixty- 
fourth  of  a  grain  of  atropine  in  solution,  which  was  done  at  3  A.   M.  by 
Dr.  Leavitt.     We  carefully  watched  the  effect  till  3  30  A.  M.,  when,  his 
violence  having  in  no  way   abated,  another  injection  was  given  in  the 
same  part  of  three-eighths  of  a  grain  of  morphine  and  one-eighth  of  a 
grain  of  atropine,  which  in  some  degree  produced  the  characteristic  effect 
of  morphine,  and  very  clearly  the  appearances  of  the  atropine  ;  for,  not- 
withstanding he  was  struggling  violently,  the  saliva,  which  had  been  very 
troublesome,  was  completely  dried  up  ;  so  much  so  that  the  patient  re- 
marked that  he  was  very  thirsty,  and  his  '  mouth  felt  as  if  he  had   been 
chewing  a  brick.'     Fifteen  drops  of  chloroform  were  then  injected,  with 
no  effect  whatever,  unless  to  weaken  his  already  weak  and  frequent  pulse. 


HYDROPHOBIA.  447 

At  4.15  A.  M.  three-eighths  of  a  grain  of  morphine  were  a  gain  intro- 
duced under  the  skin  without  atropine.  This  quieted  the  patient,  so  that 
he  was  easily  restrained,  and  he  remained  in  this  condition  from  4.30  till 
10  A,  M.,  when  the  effects  had  so  far  passed  off  that  the  attendants  were 
alarmed  at  his  violence  and  the  abundance  of  saliva  that  he  was  spitting 
from  his  mouth.  At  10.15  A.  M.  three-eighths  of  a  grain  of  morphine 
in  solution  were  injected  in  the  tissue  of  the  thigh,  which  served  to  temper 
down  the  increasing  violence  of  the  spasms,  but  did  not  stop  the  flow  of 
saliva.  I  accordingly,  at  10.45  A.  M.,  injected  three-eighths  of  a  grain 
of  morphine  and  one-fortieth  of  a  grain  of  atropine,  which  had  the  de- 
sired effect  of  producing  the  quieting  effect  of  the  morphine  and  the  spe- 
cific effect  of  the  atropia  on  the  salivary  glands.  The  poisonous  effects 
of  the  morphine  and  atropia  were  at  no  time  apparent.  He  died  at  4.15 
P.  M.  June  26,  1874,  about  twenty-four  hours  after  the  first  spasm." 

I  saw  him  at  three  o'clock  on  the  afternoon  of  the  26th  day,  and 
found  him  lying  upon  the  floor  bound  with  twisted  sheets,  the  ends  of 
which  were  held  by  his  attendants.  He  was  very  violent,  and,  though 
there  were  no  very  marked  convulsions,  he  seemed  to  be  quite 
rigid,  and  his  forearms  were  flexed  during  most  of  the  time.  He  was 
semi-comatose,  and  groaned  occasionally,  but  took  no  notice  of  those 
about  him,  and  did  not  speak.  His  respirations  were  quick,  and  there 
was  a  rattling  sound  produced  in  his  throat  with  each  expiration  and  in- 
spiration. A  quantity  of  quite  thick  mucus  and  saliva  was  spat  up  dur- 
ing my  visit,  and  there  seemed  to  be  a  very  free  secretion  of  this  sub- 
stance. The  pupils  were  widely  dilated,  and  as  far  as  I  could  judge  there 
was  no  marked  elevation  of  temperature.^ 

Recent  cases  of  hydrophobia  have  been  reported  by  Francois,^  Ed- 
wards,^ Smith,*  and  Hanscom.^  The  case  of  the  latter  is  so  interesting 
and  so  graphically  detailed,  that  I  shall  take  the  liberty  of  giving  it  in 
full. 

On  the  morning  of  the  20th  November  a  good-natured  pet  spaniel, 
which  had  never  been  known  to  snap  at  any  one,  suddenly  and  without 
any  provocation  sprang  at  his  mistress.  His  master  whipped  him,  and 
he  was  left  in  the  cellar  of  the  house  until  the  time  for  his  dinner.  When 
eating  it  in  the  company  of  a  pet  cat,  as  he  had  been  accustomed  to, 
without  ever  having  molested  her,  he  suddenly  seized  the  cat  and  threw 
her  across  the  room.  The  owner  reached  out  his  hand  to  catch  the  dog, 
when  the  latter  caught  him  tightly  by  the  wrist  and  inflicted  a  deep 
wound,  biting  him  three  times;  the  skin  became  lacerated  while  making 
an  effort  to  shake  him  off.     It  was  supposed  at  the  time  that  the  dog  was 

1  In  this  case  the  newspapers  were  filled  with  sensational  accoonts  of  the  patient's 
illness,  and  an  attempt  was  made  to  prove  that  the  dog  was  not  mad.  It  is  needless 
to  say  that  such  was  probably  not  the  case,  and  it  is  to  be  regretted  that  the  dog  was 
never  found. 

-  Bost.  Med.  and  Surg.  Journal,  May  17,  1877. 

Mbid.,  March  15,  1877. 

*  Ibid. 

5  Ibid.,  April  19,  1877. 


448  CEREBRO-SPINAL    DISEASES. 

irritable  from  the  whipping  which  he  had  received  in  the  morniug,  and, 
as  he  expected  another  for  snapping  at  the  cat,  defended  himself  by  bit- 
ing. Half  an  hour  after,  the  patient  applied  to  me  for  treatment,  and  be- 
lieving it  to  be  too  late  for  incision  or  cauterization  to  be  effective,  and  as 
there  was  no  history  of  hydrophobia,  I  dressed  the  wound  with  a  solution 
of  carbolic  acid.  It  healed  readily,  and  the  patient  attended  to  his  busi- 
ness as  usual  in  four  or  five  days.  Soon  after  the  infliction  of  the  bite 
the  dog  disappeared  and  he  did  not  return  for  thirty-six  hours  ;  nothing 
could  be  ascertained  of  his  whereabouts  or  of  his  behavior  during  that  time. 
When  he  returned  he  was  very  much  exhausted,  and  had  the  appearance 
of  having  been  severely  beaten.  From  what  I  can  learn  of  those  who  saw 
him  he  gradually  grew  weaker,  apparently  losing  the  use  of  his  legs,  espe- 
cially the  hind  ones,  which  he  would  d  rag  after  him.  He  died  quietly, 
with  his  head  in  the  lap  of  his  mistress,  without  having  had  a  convulsion, 
excessive  flow  of  saliva,  or  tremors.  On  the  13th  day  of  January  (fifty- 
four  days  alter  the  injury),  the  patient  bigan  to  have  shooting  pains  in 
the  forearm,  but  not  especially  localized.  They  did  not  radiate  from  the 
cicatrix,  and  there  w'as  no  change  in  the  appearance  of  the  latter  On  the 
following  day  the  pain  had  increased  so  much  that  he  required  one-sixtli 
of  a  grain  of  morphia  to  relieve  him  ;  it  was  given  subcutaneously,  an  I 
was  repeated  the  next  morning.  After  that  there  was  very  little  pain  in 
the  arm,  and  no  appreciable  change  in  the  pul.se  or  temperature.  He  was 
despondent,  and  stated  on  the  morning  of  the  loth  that '  he  felt  sick  and 
used  up  all  over;'  he  was  obliged  to  go  to  bed  in  the  afternoon,  and  then 
for  the  first  time  began  to  have  some  difficulty  in  swallowing.  This  symp- 
tom was  not  manifested  by  an  attempt  to  drink  water,  but  during  an  effort 
to  swallow  some  herb  tea  which  he  was  accustomed  to  take  when  ill,  and 
which  he  believed  would  relieve  his  bad  feelings.  There  was  no  trismus  ; 
he  was  quiet  and  inclined  to  d(,'ze.  At  5  P.  M.  Dr.  H.  H.  A.  Beach  saw 
the  patient  with  me,  and  agreed  that  the  history  of  the  case  in  connection 
with  the  symptoms  then  existing  indicated  the  probable  development  of 
hydrophobia,  and  an  unfavorable  prognosis  was  given  to  the  patient's 
brother,  who  promised  not  to  communicate  it  to  the  patient  or  his  friends 
until  the  disease  should  be  fully  declared.  His  pulse  at  this  time  was  102, 
and  the  temperature  in  the  axilla  102^  F  ,  face  flushed,  tongue  coated. 
The  cicatrix  presented  no  unusual  appearance,  nor  was  it  tender.  A  dark 
room  was  agreeable  to  him,  but  on  raising  the  curtains  the  light  did  not 
disturb  him  in  the  least.  He  was  perfectly  rational,  and  had  some  thirst, 
but  no  sore  throat.  He  made  an  attempt  to  swallow  a  teaspoonful  of  milk, 
but  was  obliged  to  give  it  up  from  the  moment  that  the  fluid  touched  his 
lips.  Immediately  after  this  attempt  unmistakable  spasmodic  contraction 
of  muscles  between  the  chin  and  sternum  was  observed.  Mentally  the 
patient  was  perfectly  clear,  and  not  disturbed  by  the  unsuccessful  attempt 
at  swallowing  fluids,  but  said  he  would  try  it  again  when  he  should  be 
more  thirsty.  This  symptom,  excepting  when  he  swallowed  teaspoonful- 
doses  of  medicine,  continued  until  his  death.  He  was  obliged  to  relieve 
his  thirst  by  sucking  ice  and  snow  through  a  napkin.  The  air  from  a 
fan  or  from  adjusting  the  bed-clothing  caused  a  shudder.  Occasional 
sighing  was  noticed  after  the  second  day  ;  it  grew  deeper  and  more  fre- 
quent until  the  end.  When  disturbed  from  any  cause,  his  respiration 
was  of  a  spasmodic  character,  so  much  so  at  times  as  to  interfere  with  his 
speech. 

On  the  following  morning  (the  16th)  his  pulse  was  96,  and  mild  de- 


HYDROPHOBIA.  449 

lirium  first  developed ;  this  also  continued  until  his  death.  He  was  easily 
controlled  throughout  the  disease.  He  became  very  suspicious  of  the 
people  about  him,  believing  that  they  were  attempting  to  make  him  the 
victim  of  practical  jokes,  then  of  being  poisoned.  One  hallucination 
was  continuous  from  the  time  that  the  delirium  first  developed :  he 
thought  that  some  one  had  thrown  a  dirty  powder  on  him,  and  he  was 
continually  making  efibrts  to  shake  it  off  from  himself  and  his  clothing. 
He  was  also  very  cross  and  dictatorial,  but  showed  no  disposition  to  snap 
or  bite. 

Between  four  and  five  P.  M-  on  the  18th  he  began  to  have  spasmodic 
contraction  of  the  muscles  of  the  chest,  larynx,  and  throat;  some  of  them 
lasted  nearly  a  minute,  and  prevented  him  from  taking  an  inspiration. 
He  also  had  a  profuse  dischflrge  of  saliva  sufiicient  to  wet  his  clothing 
through  from  his  chin  down  to  his  hips.  The  spasmodic  contractions  con- 
cerned in  respiration  exhausted  him  rapidly,  and  he  died  quietly  at  8.15, 
while  sitting  up  in  a  chair.  This  position  became  necessary  from  the  fact 
that  he  could  not  lie  on  his  side,  and  if  on  his  back  the  saliva  accumulated 
so  rapidly  that  it  obstructed  his  respiration.  For  the  last  twenty  minutes 
before  his  death  there  was  no  spasm.  He  lived  five  days  after  the  first 
general  symptom.  At  no  time  was  he  disturbed  by  the  sound  of  ringing 
bells  or  running  water.  Morphia  in  one-fourth-grain  doses,  and  chloral 
and  bromide  of  potassium  in  fifteen-grain  doses  of  each  at  the  same  time 
were  given  as  needed.  Ansesthetics  were  not  required.  At  the  solicita- 
tion of  his  friends  he  was  allowed  to  take  a  j^ill,  the  prescription  for 
which  was  said  to  be  one  hundred  years  old  and  to  have  cost  originallv 
five  hundred  pounds.  It  had  the  reputation  of  curing  and  preventing 
many  cases  of  the  disease.  ISTo  change  in  his  symptoms  could  be  attributed 
to  its  action,  nor  could  its  composition  be  ascertained.  It  was  given  as  a 
placebo,  on  the  chances  that  an  hysterical  element  existed  in  this  case ; 
that  whatever  offered  encouragement  to  the  patient  without  the  possi- 
bility of  injury  in  his  hopeless  condition  was  justifiable,  but  so  far  as  the 
evidence  furnished  by  one  case  is  of  value  its  inefficacy  was  demonstrated. 
The  permission  of  his  friends  for  an  autopsy  could  not  be  obtained.  The 
particular  symptoms  of  the  disease  which  were  not  observed  in  the  dog 
when  seen  might  have  existed  during  the  thirty-six  hours  that  he  was  absent. 

The  proximity  of  the  wound  to  the  ulnar  nerve  and  its  character 
(punctured  and  lacerated)  suggested  the  consideration  of  tetanus  as  an 
explanation  of  the  symptoms  ;  the  latter  seemed  to  be  fairly  excluded, 
however,  on  the  ground  that  delirium  was  continuous  from  the  third  day 
of  the  attack,  and  that  at  no  time  did  trismus  or  any  other  form  of  tonic 
spasm  exist ;  the  profuse  discharge  of  saliva  was  also  corroborative  of  this 
view.  The  unquestionable  existence  of  repeated  attacks  of  laryngeal 
spasm  ;  the  fact  that  the  symptoms  developed  after  a  considerable  interval 
had  elapsed  from  the  date  of  the  injury  ;  that  for  three  hours  previous  to 
his  death,  and  after  he  became  wholly  unconscious,  marked  spasms  of  the 
chest  and  throat  occurred  at  intervals  of  from  three  to  five  minutes;  that 
death  occurred  as  a  result  and  within  five  days  following  the  development 
of  symptoms  characteristic  of  the  disease,  reasonably  offset  a  theory  that 
the  hydrophobic  symptoms  were  simulated  by  an  hysterical  man. 

In  Smith's  case  the  period  of  incubation  was  about  two  months,  and  the 
paroxysms  were  ushered  in  by  vomiting,  fear  of  water,  and  febrile  symp- 
toms.    On  the  third  day  of  the  disease  he  became  delirious,  and  on  the 
29 


450  CEREBKO-SPINAL    DISEASES. 

fourth  died.  The  sound  made  by  the  patient,  which  is  so  often  compared 
to  the  bark  of  a  dog,  was  likened  by  the  author  to  that  made  by  a  croupy 
child.  In  Edwards's  case,  the  period  of  incubation  was  about  five  months. 
The  injury  was  insignificant,,  but  with  the  invasion  of  the  disease  there 
was  pain  in  the  cicatrix  which  extended  up  the  arm.  In  this  patient 
there  was  also  dread  of  fluids,  especially  water.  On  the  second  day  the 
convulsions  began.  The  same  day  she  spat  up  bloody  mucus.  At  the 
end  of  sixty  hours  from  the  first  local  pain  she  died. 

Causes. — The  circumstances  which  concern  the  etiology  are  still 
enshrouded  in  mystery.  Some  authors  are  of  the  opinion  that  rabies  may 
be  communicated  by  a  dog  that  is  not  mad,  and  cases  are  brought  forward 
to  prove  this  theory.  I  cannot  agree  with  this,  for  it  seems  to  me  highly 
improbable  that  there  should  be  so  few  cases  of  this  disease  if  the  bite  of 
a  non-rabid  animal  can  inoculate  an  individual.  Bouley  states  that  in  no 
way  can  the  disease  be  transmitted  other  than  by  inoculation  with  the  saliva. 
In  this  statement  he  receives  the  endorsement  of  Magendie  and  others. 
Another  point  remains  to  be  answered,  and  this  is  in  regard  to  the  trans- 
mission of  virus  from  one  person  to  another  without  the  second  person 
being  bitten.  Fleming  has  given  an  example  which  shows  that  this  may 
take  place. 

In  the  spring  of  the  present  year  I  was  subpoenaed  to  serve  as  a  jury- 
man in  the  case  of  a  boy  who  had  died  of  rabies.  At  about  the  same 
time  another  death  occurred  which  the  attending  physician  said  was 
simply  the  result  of  fear,  and  not  of  hydrophobia.  A  careful  inquiry  and 
examination  of  witnesses  revealed  the  following  history,  which  I  think 
proved  beyond  a  doubt  that  the  cause  of  death  in  both  cases  was  the 
bite  of  a  rabid  cat.  This  cat  had  found  her  way  into  a  stable  on  Thirty- 
fourth  Street,  and  had  bitten  a  horse.  This  horse  afterwards  died  in  con- 
vulsions, and  from  all  I  could  learn  the  cause  of  death  was  hydrophobia. 
In  an  adjoing  yard  the  cat  bit  one  of  the  boys,  who  also  died,  and  in  a 
few  days  afterwards  bit  the  other  boy,  whose  inquest  we  attended.  Both 
of  these  victims  died  within  a  short  time  of  each  other.  In  one  of  these 
cases  there  was  but  a  slight  scratch. 

Morbid  Anatomy  and  Pathology. — Cliflfbrd  Albutt,^  Meynert, 
Elder,'-'  and  others  have  made  autopsies,  and  still  there  seems  to  be  very 
little  light  thrown  upon  the  pathogeny  of  the  disease.  Albutt  found  en- 
largement of  vessels  in  the  cerebral  convolutions,  pons,  medulla,  and 
spinal  cord,  and  granular  disintegration.  Elder  found  absolutely  nothing ; 
and  the  results  of  the  search  of  Lockhart  Clarke  who  examined  parts 
of  the  brain,  medulla,  and  cord,  were  equally  negative. 

Kolesnikoff^  reported  the  appearance  of  the  nervous  centre  in  ten  dogs 
that  had  died  of  hydrophobia.  "  The  jDarts  examined  included  the  hemi- 
spheres, corpora  striata,  thalami  optici,  cornua  ammonis,  cerebellum,  me- 
dulla oblongata,  spinal  cord,  the  sympathetic  and  vertebral  ganglia.  The 

*  Med.  Kecord,  i.  22.  -  Britiph  Med.  Jour.  vol.  ii.  1874. 

3  Centralblatt  fiir  Med.  Wissen.,  No.  50, 1875.  Abst.  Phil.  Med.  Times,  Feb.  5, 1876. 


HYDROPHOBIA.  451 

most  marked  changes  were  observed  in  the  two  latter,  and  were  as  fol- 
lows: 1.  The  vessels  were  enlarged,  choked  with  red  blood-corpuscles; 
occasionally,  extravasated  red  corpuscles  and  round  indifferent  elements 
(probably  white  corpuscles)  were  found  in'the  perivascular  spaces.  The 
walls  of  the  vessels  were  here  and  there  filled  with  hyaloid  masses  of 
various  forms,  which  occasionally  extended  into  the  lumen  of  the  vessels, 
and  closed  this  as  a  thrombosis  would.  Not  far  from  these  masses  collec- 
tions of  white  and  red  biood-corpuscles  could  be  observed,  the  latter  de- 
prived of  color.  They  could  be  seen  also  in  all  stages  of  metamorphosis 
into  hyaloid  globules.  2.  In  the  pericellular  spaces  of  the  nerve-cells 
could  be  observed  collections  of  round  indifferent  elements,  whose  pene- 
tration, to  the  number  of  five  to  eight  or  even  more,  pressed  out  the  pro- 
toplasm of  the  cells.  This  penetration  of  the  elements  spoken  of  was 
frequently  sufficient  to  change  the  form  of  the  nerve-cells,  giving  them 
at  different-times  a  sac-formed,  bulged,  or  flattened-out  appearance.  Fur- 
ther, the  nucleus  was  sometimes  pushed  towards  the  periphery  of  the  cell 
and  surrounded  by  many  round  elements.  In  other  cases,  only  groups  of 
round  (indifferent)  bodies  could  be  observed  in  place  of  the  nerve-cells. 
In  isolated  nerve-cells  the  changes  described  could  also  be  observed." 

The  body  of  Dr.  Hadden's  patient  was  examined  by  the  deputy  coro- 
ner and  several  physicians,  among  whom  were  Drs.  Clymer,  Hammond, 
Cross  and  myself.  The  calvarium  was  removed,  and  great  congestion  of 
the  meninges  and  brain  was  observed.  The  sinuses  were  much  engorged, 
but  there  was  very  little  effusion  either  upon  the  surface  of  the  brain  or 
in  the  ventricles.  The  lower  surface  of  the  brain  appeared  to  be  slightly 
softened  in  patches,  but  there  was  nothing  else  to  attract  attention,  ex- 
cept it  might  perhaps  have  been  a  great  hardness  of  the  pituitary  body. 
The  internal  viscera  were  all  hyperaamic,  but  there  was  no  other  morbid 
apperances.  The  larynx  and  trachea  were  found  to  be  very  much  in- 
jected, and  the  latter  contained  a  quantity  of  frothy  mucus.  Dr.  Willis 
has  found  the  blood  of  persons  who  have  died  from  this  disease  to  be  very 
fluid  and  of  a  dark  color.  Dr.  Shattuck  and  Fitz  ^  have  published  the 
notes  of  an  interesting  case  of  hydrophobia  treated  unsuccessfully  by 
them.  An  immense  amount  of  curare  was  given,  about  four  grains  within 
six  hours,  without  any  of  the  physiological  effects  being  produced,  though 
the  drug  was  of  good  quality.  Dr.  Fitz's  subsequent  examination  is  of 
so  much  interest  and  so  full  that  I  present  such  parts  of  it  as  relate  to 
the  change  in  the  nervous  tissues  : 

"  While  exposing  the  spine  the  surrounding  tissue  seemed  to  contain 
less  fluid  than  usual.  No  abnormal  appearances  were  observed  in  the 
membranes  of  the  spinal  cord,  or  upon  the  surface  of  sections  made  across 
the  latter  at  intervals  of  an  inch  throughout  its  length. 

The  calvaria  was  readily  separated  from  the  dura  mater,  both  the 
bone  and  the  membrane  j)resenting  no  unusual  appearances.  The  lon- 
gitudinal sinus  contained  a  soft  gelatinous  clot,  only  partially  filling   the 

1  Boston  Medical  and  Surgical  Journal,  Aug.  28,  1878. 


4o2  CEREBRO-SPI^'AL    DISEASES. 

cavity.  The  pia  mater  -was  occasionally  spotted  and  streaked  from 
fibrous  thickening,  and  was  unusually  injected  over  the  greater  part  of 
the  convexity  of  the  brain,  the  vessels  being  often  varicose.  The 
meshes  contained  a  considerable  excess  of  clear  fluid,  and  the  membrane 
was  readily  detached  from  the  brain.  On  section  of  the  brain  no  un- 
usual appearances  were  observed  in  the  ventricles  or  cerebral  substance 
beyond  abundant  puncta  cruenta. 

The  chief  interest  naturally  centered  in  the  possible  condition  of  the 
nervous  system,  and  the  spinal  cord,  medulla  oblongata,  and  portions 
of  the  cerebral  convolutions  were  preserved  in  Midler's  fluid  for  the 
purpose  of  microscopical  examination.  Positive  results  were  obtained 
from  the  medulla  alone ;  it  should  be  stated,  however,  that  the  cord- 
was  perfectly  hardened,  so  that  the  sections  obtained  from  it  were 
comparatively  useless.  The  changes  found  in  the  medulla  were  ob- 
served throughout  its  length,  and  were  most  commonly  met  with  in  the 
posterior  portion,  especially  in  the  immediate  vicinity  of  the  floor  of  the 
fourth  ventricle.  The  alterations  were  most  extreme  in  that  part  corres- 
ponding with  the  calamus  scriptorius.  The  appearance  most  frequently 
met  with  was  infiltration  of  the  adventitia  of  the  veins  with  small,  round 
cells,  both  large  and  small  veins  being  affected.  So  abundant  was  their 
distribution  that  upon  longitudinal  section  the  wall  of  the  vessel  seemed 
to  be  paved,  as  it  were,  with  these  cells.  As  a  rule,  the  vessels  thus 
modified  were  distended  with  blood,  and  it  seemed  probable  that  the  ob- 
served changes  were  pathological,  as  the  vessels  in  other  parts  of  the 
medulla  did  not  present  such  an  appearance.  The  injection  of  the  veins 
was  so  complete  at  times  that  their  section  was  of  a  dark-brown  color  and 
quite  opaque,  the  individual  corpuscles  being  indistinct,  and  the  condi- 
tion deserved  to  be  spoken  of  as  a  thrombosis.  It  was  evident  from 
transverse  sections  that  the  different  cells  were  not  simply  adherent  to  the 
inner  surface  of  the  vessel,  but  were  actually  within  the  wall,  nor  was 
there  any  evidence  of  an  increase  in  the  relative  proportion  of  white  to 
red  blood-corpuscles. 

Another  appearance  often  met  with  was  that  of  haemorrhage.  In 
general  the  extravasated  blood  was  found  within  the  perivascular,  particu- 
larly venous,  spaces.  The  sharply-defined  outline  of  the  corpuscles  and 
the  absence  of  granules  of  blood-pigment  indicated  that  the  hemorrhages 
were  recent.  Transverse  sections  of  the  injected  vessel,  with  its  wall  in 
filtrated  with  round  cells,  and  a  perivascular  accumulation  of  red  blood- 
corpuscles,  were  often  met  with.  In  none  of  the  sections  were  ruptures  of 
the  vessel  wall  seen.  At  times  the  wall  was  somewhat  collapsed,  the  contents 
correspondingly  less,  while  around  the  vessel  a  considerable  hiemorrhage- 
was  apparent.  The  hosmorrhages  were  usually  limited  to  the  perivasc- 
ular space,  the  blood  rarely  having  made  its  way  between  the  nerve  fibres 
or  into  the  gray  matter. 

Finally,  an  appearance  was  sometimes  met  with  which  may  be  spoken 
of  as  a  miliary  abscess.  Occasional  minute  agglomerations  of  indiffer- 
ent cells  were  seen,  but  their  relation  was  such  as  to  suggest  their  prob- 


HYDROPHOBIA.  453 

able  origin  from  sections  througli  limited  portions  of  the  infiltrated  ad- 
ventitia  already  referred  to.  In  two  instances,  however,  actual  abscesses 
were  found, — one  wifhin  a  convolution  of  the  olivary  nucleus,  another  in 
the  immediate  vicinity  of  a  pigmented  ganglion  cell  in  the  upper  part 
of  the  medulla.  The  former  was  a  larger,  and  it  was  found  in  a  part 
where  none  of  the  cellular  infiltration  of  the  vessels  already  mentioned 
was  observed. 

In  brief,  then,  the  alterations  were  a  difiuse  cellular  infiltration  of  the 
adventitia  of  the  veins,  venous  injection  and  thrombosis,  perivenous 
hsemorrhages,  and  miliary  abscesses." 

The  question  to  be  answered  after  all  is,  whether  this  affection  is  a  pri- 
mary disorder  of  the  nervous  centres  or  whether  it  is  the  result  of  general 
blood-poisoning.  I  am  inclined  to  accept  the  latter  theory,  as  the  array  of 
facts  is  too  meagre  to  permit  any  positive  assertion  as  to  its  nervous  ori- 
gin. Like  other  disorders,  not  essentially  nervous,  there  is  a  period  of  in- 
oculation, or  incubation,  of  invasion,  and  development.  I  think,  then, 
that  in  this  respect  this  disease,  as  well  as  tetanus,  resembles  closely  some 
of  the  exanthemata. 

Diagnosis. — It  is  important  to  bear  in  mind  the  fact  that  a  great 
many  so-called  cases  of  hydrophobia  are  not  this  disease  at  all,  and  that 
certain  forms  of  hysteria  bear  to  it  a  close  resemblance.  Fright  may 
act  so  powerfully  upon  the  nervous  system  that  a  train  of  symptoms  -may 
be  produced  very  much  like  those  of  the  genuine  affection.  A  case  of  this 
kind  occurred  at  Bellevue  Hospital  a  year  or  two  ago,  in  which  the 
symptoms  counterfeited  those  of  the  real  disease  in  every  respect,  and  the 
patient  finally  died.  It  was  found  that  the  individual  had  not  only  never 
been  bitten,  but  that  he  actually  died  of  fear,  his  imagination  having  been 
stimulated  by  the  sensational  articles  in  the  newspapers.  Dr.  J.  W-  S. 
Arnold,  of  the  University,  who  examined  the  brain  and  cord,  was  unable 
to  find  the  slightest  indication  of  any  morbid  change.  The  only  other 
conditions  from  which  we  may  be  required  to  make  a  differential  diagnosis 
are  tetanus.  Calabar  bean,  and  picrotoxin  poisoning.  In  the  former  there 
are  many  points  of  resemblance,  and  occasionally  a  dread  of  liquids  and 
a  difiiculty  in  swallowing.  In  tetanus,  however,  the  risus  sardonicus 
is  present,  the  spasms  are  tonic,  and  there  is  opisthotonos,  and  the  mind 
is  clear  to  the  last. 

In  poisoning  by  both  agents,  to  which  I  have  alluded,  the  rapidity  of 
their  action  is  conspicuous,  and  a  dose  of  either  would  carry  the  patient 
off  in  a  few  hours,  more  or  less.  In  picrotoxin  and  Calabar  bean  poi- 
soning, there  are  many  of  the  symptoms  of  hydrophobia,  such  as  clonic 
spasms,  frothing,  rise  of  temperature  ;  but  no  dread  of  water,  nor  delirium. 

Epilepsy  may  resemble  hydrophobia,  but  it  is  only  when  the  attacks  are 
numerous  and  closely  connected  that  such  a  mistake  could  possibly  occur. 

Marbaix^  "gives  a  case  of  epileptiform  convulsions  more  or  less  resem- 
bling hydrophobia,  in  a  man  who  had  been  bitten  four  days  before  by  a 

1  Presse  M6d.  Beige,  1869,  237. 


454  CEREBRO-SriJfAL.    DISEASES. 

cat ;  they  were  accompanied  by  delirium  and  hypersesthesia  of  the  optic 
nerve,  a  stray  light  thrown  across  his  eyes  causing  a  convulsive  attack. 
The  shortness  of  the  incubation,  the  blueness  of  the  face,  without  the 
'vultueuse'  expression  characteristic  of  hydrophobia,  the  delirium,  and 
the  melancholy,  not  exalted,  condition,  combined  with  a  history  of  an 
epileptic  attack  a  year  before,  prevented  the  case  being  looked  upon  as 
one  of  true  hydrophobia." 

Prognosis. — In  true  hydrophobia  it  is  very  bad.  I  believe  there 
never  have  been  more  than  one  or  two  genuine  cures  reported  ;  and  if 
others  have  been  claimed,  it  is  probable  that  no  rabies  existed,  but  that 
the  affection  described  was  simply  hysterical.  The  chance  of  inoculation 
seems  to  be  a  matter  of  interest,  for  of  the  reported  cases  in  which  indivi- 
duals have  been  bitten,  it  has  been  found  that  about  two-thirds  of  them 
subsequently  developed  symptoms  of  rabies. 

Treatment. — We  rarely  see  these  patients  until  actual  evidences  of 
madness  have  appeared.  If,  however,  we  are  fortunate  enough  to  be 
called  to  the  individual  immediately  after  he  has  been  bitten,  we  may 
either  incise  or  cauterize  the  wound.  It  is  well  to  ligate  the  limb  as  soon 
as  possible,  and  then  remove  en  masse  the  piece  of  the  muscle  which  has 
been  penetrated  by  the  teeth  of  the  rabid  animal.  Various  writers  re- 
commend the  cupping-glass,  which  should  be  applied  to  the  excised  part 
till  it  abstracts  several  ounces  of  blood  from  the  wound.  A  pencil  of  ni- 
trate of  silver  may  be  thrust  into  the  punctures  made  by  the  teeth  of  the 
dog  until  they  are  well  cauterized,  and  a  strong  solution  (5ij~^j)  should 
be  applied  afterwards  by  means  of  a  piece  of  folded  linen,  which  is  to  be 
covered  by  oil  silk. 

I  am  convinced  that  no  remedy  can  do  good  where  the  disease  has  al- 
ready appeared,  except,  perhaps,  curare,  which  has  been  tried ;  and  in 
one  case,  where  it  was  prescribed  by  Dr.  Austin  Flint,  Sr.,  it  is  said  to 
have  saved  the  patient's  life. 

The  case  must  be  desperate,  however,  when  this  powerful  substance  is 
resorted  to,  for  its  preparation  is  not  always  the  same,  and  no  two  speci- 
mens are  of  the  same  strength.  It  has  been  injected  hypodermically  in 
doses  of  one  grain. 

Oftenberg^  reports  the  cure  of  a  girl  of  eighteen.  She  received  at  first 
hypodermic  injections  of  morphine  and  chloroform,  but  there  was  no  im- 
provement in  her  condition.  Seven  hypodermic  injections,  aggregating 
three  grains  of  curare,  were  afterwards  given  in  the  course  of  six  hours. 
The  muscular  disturbance  subsided  at  once,  and  there  was  ultimate  reco- 
very. The  convulsions  were  succeeded  by  paralysis,  which  gradually 
disappeared. 

Hot  baths  have  been  recommended,  but  I  cannot  find  that  they  have 
ever  cured  a  case  of  this  kind. 

HYSTERIA. 
Synonyms. — Hysterie  (Fr.)   Muttersucht  (Ger.)  Vapors. 
1  Wien.  Med.  Presse,  1876,  No.  1. 


HYSTERIA.  455 

Definition. — It  would  be  almost  impossible  to  give  a  concise  defini- 
tion of  this  most  protean  of  nervous  affections,  for  it  simulates  a  multitude 
of  organic  and  functional  diseases  so  perfectl}^,  that  the  task  of  considering 
it  in  any  systematic  manner  would  be  attended  with  great  difficulty.  The 
nervous  system  in  this  respect  is  like  the  "  general  utility "  actor.  It 
plays  the  most  varied  parts.  Sometimes  we  are  presented  with  a  hemi- 
plegia or  paraplegia,  and  at  others  with  contractures  which  seem  to  be  the 
result  of  organic  disease,  so  permanent  and  intractable  do  they  appear. 
Convulsions,  ansesthesia,  urinary  and  other  troubles  of  a  more  or  less 
grave  character,  swell  the  list,  until  we  are  almost  inclined  to  look  upon 
it  as  a  "  disease  of  the  Devil,"  and  cease  to  wonder  at  the  credulity 
and  superstition  of  those  who  believe  in  demoniac  possession  and  witch- 
craft. Confining  ourselves  as  closely  to  the  subject  as  possible,  we  con- 
clude that  hysteria  is  a  disease  of  an  emotional  character  chiefly  among 
women,  in  which  the  symptoms  are  rarely  the  same  in  any  two  instances, 
but  among  a  large  number  of  cases  there  can  be  noticed  a  certain  simi- 
larity. 

Symptoms. — These  symptoms  may  be  grouped  as  sensorial,  motorial, 
and  visceral.  Sensorial  symptoms  are  of  three  kinds  ;  hypersesthetic, 
anaesthetic,  and  mental.  Hypersesthesia,  though  much  more  common 
than  anaesthesia,  is  not  so  marked.  Large  areas  of  hypereesthesia  may  be 
detected  by  careful  examination,  though  the  patient  usually  saves  this 
trouble,  for  she  calls  attention  to  the  weight  of  her  clothes,  the  pressure  of 
some  fold  of  her  underwear,  or  the  contact  of  some  very  light  substance 
which  is  pronounced  unbearable.  The  external  organs  of  generation  are 
extremely  sensitive,  and  the  slightest  touch  of  the  finger  or  speculum  pro- 
duces a  spasm  and  great  agony.  Coition  is  impossible,  and  one  patient 
called  my  attention  to  a  horrible  shooting  pain  which  occurred  whenever 
her  husband  approached  her.  Hypersesthesia  about  the  nipples,  at  the 
end  of  the  coccyx,  and  in  other  parts  of  the  body,  is  alluded  to  by  vari- 
ous writers.  Charcot  has  directed  attention  to  the  prominence  of  these  ; 
and  Briquet  has  described  fixed  pains  of  the  abdomen  which  he  called 
ccelalgice,  and  of  450  cases  he  found  200  presenting  this  symptom.  They 
were  hypogastric  and  iliac,  but  more  commonly  the  latter.  These  have 
sometimes  been  mistaken  for  the  pain  of  peritonitis  ;  there  is,  however, 
no  tenderness,  but  simply  superficial  elevation  of  sensibility.  The  pa-  1 
tient  often  calls  attention  to  vague  pains  in  different  parts  of  the  body,  of  J 
a  transitory,  and  sometimes  permanent  character.  She  complains  of 
strong  light  and  loud  noises,  and  insists  upon  perfect  quiet,  although  she 
will  herself  talk  and  cry  in  a  very  noisy  manner.  All  of  her  pains  are 
increased  when  her  attention  is  concentrated  upon  them,  but  when  her 
mind  is  diverted  she  will  bear  very  rough  treatment  without  complaint. 

Neuralgic  pain,  a  familiar  variety  being  the  clavus  hystericus,  is  a  com- 
mon form  of  complaint.  Various  local  pains  are  also  experienced,  and 
these,  among  others,  include  alterations  in  sensibility  which  simulate  lum- 
bago ;  indeed,  a  very  constant  hysterical  complaint  is  backache,  which 
the  patient  generally  attributes  to  the  kidneys.     A  most  interesting  form 


456  CEREBRO-SPIN^AL    DISBASES. 

of  hysterical  dyssesthesia  has  received  mention  from  Skey,  Paget,  and 
others,  and  is  very  often  mistaken  for  rheumatism.  The  joints  are  neither 
swollen  nor  red,  however.  ]M.  Meyer,'  in  an  interesting  article  upon 
the  subject,  gives  the  leading  points  in  diagnosis  as  follows  :  "  1.  The  neu- 
ralgia is  of  a  diurnal  form  entirely.  2.  Light  pressure  of  joints  produces 
pain,  but  comparatively  violent  handling  is  not  at  all  painfnl.  3.  The 
temperature  of  the  affected  joint  undergoes  variations.  4.  There  is  no 
loss  of  substance  of  the  muscles  of  an  unsound  limb.  5.  The  cure  is 
usually  spontaneous."  The  mental  disturbances  are  of  the  most  interest- 
ing character,  whether  expressed  by  transient  emotional  excitement  or 
apparent  prolonged  unconsciousness.  Examples  of  the  lighter  grades  are 
too  familiar  to  need  description,  and  it  is  only  necessary  to  allude  to  the 
outbursts  of  immoderate  laughter  or  crying  which  occur  when  there  is  no 
reason  for  either  emotional  elation  or  depression.  Such  individuals  may 
indulge  in  laughter  at  church  or  at  a  funeral,  and,  while  perfectly  aware 
of  the  impropriety  of  their  conduct,  will  be  utterly  unable  to  restrain 
themselves.  Illusions,  hallucinations,  and  even  delusions  are  evidences 
of  a  very  irritable  condition  of  the  nervous  centres,  as  are  ecstasy  and 
mental  excitement  of  various  kinds,  such  as  belief  in  impending  calamity 
or  death.  The  involuntary  use  of  foul  words  and  gestures,  and  a  remarka- 
ble eccentricity  of  behavior,  are  additional  suggestions  of  a  disordered 
state  of  the  emotions.  Wynter,-  in  his  excellent  little  book,  thus  alludes 
to  a  condition  which,  after  all,  is  but  a  manifestation  of  hysteria. 

"  There  is  a  terrible  stage  of  consciousness  in  which,  unknown  to  any 
other  human  being,  an  individual  keeps  up  as  it  were  a  terrible  hand-to- 
hand  conflict  with  herself  when  she  is  prompted  by  an  inward  voice  to  use 
disgusting  words,  which,  in  her  sane  moments,  she  loathes  and  abhors. 
These  voices  will  sometimes  suggest  ideas  which  are  diametrically  opposed 
to  the  sober  dictates  of  her  conscience.  In  such  conditions  of  mind, 
prayers  are  turned  into  curses,  and  the  chastest  into  the  most  libidinous 
thoughts."  ^  The  will  is  quite  weak,  while  the  emotions,  far  from  being 
held  in  abeyance  to  the  extent  which  they  are  in  health,  respond  to  trivial 
ideational  impressions.  The  hysterical  person  firmly  believes  herself  to 
be  the  subject  of  various  disorders  of  a  greater  or  less  serious  character  ; 
is  hopeless  ;  believes  in  a  speedy  fatal  termination  of  her  imaginary 
trouble ;  and  can  only  be  convinced  of  her  mistake  by  fear  of  the  reme- 
dy suggested,  or  by  some  strong  appeal  to  her  appetite  or  comfort.  While 
in  a  state  which  may  sometimes  appal  the  observer,  the  patient  declares 
her  inability  to  walk.  If,  however,  some  powerful  excitement  be  pro- 
duced, such  as  an  alarm  of  fire,  she  quickly  recovers  the  use  of  her  legs. 
I  have  recently  seen  a  most  interesting  case  of  hysterical  torticollis,  in 

^  Berliner  Klin.  Woch.,  1874,  No.  26.  -  Borderland  of  Insanity,  p.  3. 

3  Hysterical  girls  and  women  occasionally  evince  a  depraved  appetite,  eating  all 
sorts  of  extraordinary  things.  The  school-girl  habit  of  eating  slate-pencils  is  an  ex- 
ample of  this.  I  have  personally  observed  this  evidence  of  hysteria  on  many  occa- 
sions. A  young  lady  recently  under  treatment  ate  enormous  quantities  of  nutmegs- 
The  morbid  appetite  of  pregnancy  is  probably  an  hysterical  disorder. 


HYSTERIA.  457 

whicli  the  patient  refused  to  turn  or  raise  her  head.  I  quietly  seated  my- 
self at  her  other  side,  and  engaged  her  attention  so  fully  that  after  a 
while  she  turned  her  head  and  talked  for  some  time ;  and  it  was  only 
when  I  referred  to  the  subject  of  her  troubles  that  she  quickly  resumed 
her  original  position,  and  I  could  not  persuade  her  to  change  it.  She  may 
at  times  believe  that  she  is  deaf  or  dumb,  and  remain  in  such  an  uncom- 
fortable condition  for  years,  punishing  not  only  herself,  but  making  all 
about  her  uncomfortable. 

One  of  the  most  striking  mental  characteristics  of  the  hysterical  woman  is 
her  utter  want  of  confidence  in  herself.  She  relies  upon  all  those  about  her, 
and  goes  to  her  physician  at  all  hours  and  with  no  object  in  view  except 
the  need  for  sympathy.  She  often  has  an  impending  dread  of  some  ca- 
lamity, and  requires  constant  reassurance.  If  the  physician  could  give 
her  the  belief  that  she  could  control  her  own  emotions  and  conquer,  much 
might  be  done.  She  even  may  know  how  unsubstantial  are  her  symptoms 
— her  paralysis,  for  instance,  but  she  says  "  I  cannot  help  it ;  I  have  every 
desire  to  move  my  leg,  or  my  arm,  but  I  know  that  I  cannot." 

Hysterical  anaesthesia  has  received  a  great  deal  of  attention  of  late 
years  from  the  French  observers,  especially  from  Charcot,  as  well 
as  Piorry  and  Gendrin.  Briquet^  has  found  that  this  condition  oc- 
curs more  frequently  on  the  left  than  upon  the  right  side.  It  may  be 
superficial  or  deep,  even  afiectiug  the  muscles  and  bones.  Reynolds  has 
found  it  limited  often  to  the  back  of  the  hand  or  foot,  or  about  the  mouth 
and  nose.  The  vaginal  canal  and  the  lining  mucous  membrane  of  the 
mouth  are  also  places  where  there  may  be  loss  of  sensation.  Hysterical 
hemianaesthesia  does  not  diflfer  from  that  due  to  cerebral  hemorrhage  so 
far  as  the  symptomatology  is  concerned.  The  same  regions  are  affected 
and  the  same  complicated  amblyopia  takes  place.  Taste  and  smell 
are  unilaterally  involved.  Hysterical  anaesthesia  not  rarely  follows, 
or  comes  on  during  a  convulsive  attack,  and  lasts  for  a  variable  time.  It 
may  subside  in  a  few  hours,  or  continue  for  months  at  a  time.  During  its 
existence  the  most  violent  stimuli  will  fail  to  restore  sensibility ;  and  I 
have  often  used  powerful  counter-irritants,  electricity,  or  even  the  hot 
iron,  without  any  response  whatever.  The  loss  of  sensation  may  extend 
more  deeply,  so  that  the  underlying  muscles  may  be  utterly  without  sen- 
sation. This  peculiarity  probably  explains  the  insusceptibility  to  pain 
spoken  of  by  Carre  de  Montegeron.  The  Jansenists  or  Convulsionnaires 
"  became  so  wrought  up  by  religious  excitement  that  they  fell,  twenty  or 
more  at  a  time,  into  violent  coavul^ions,  and  demanded  to  be  beaten  with 
huge  iron-shod  clubs,  in  order  to  be  relieved  of  an  unbearable  pressure 
upon  the  abdomen.  One  of  the  brothers  Marion  felt  nothing  of  the 
thrusts  made  by  a  sharp-pointed  knife  against  his  abdomen." 

Not  only  may  there  be  analgesia,  but  loss  of  appreciation  of  heat  or 
cold,  and  the  surface  may  become  blanched  and  white,  and  the  skin  even 
bloodless.     Brown-Sequard  has  demonstrated  the  absence  of  blood  ;  a  fact 

^  Traite  Clinique  et  Therapeutique  de  I'Hysterie,  Paris,  1859. 


458  CEREBRO-SPINAL    DISEASES. 

which  has  an  historical  interest  in  connection  with  the  tests  of  the  early- 
religious  enthusiasts.  Charcot  alludes  to  the  epidemic  of  St.  Medard, 
when  the  cut  of  a  sword  failed  to  produce  any  flow  of  blood.  The  tem- 
perature of  the  anrcsthetic  spot  is  sometimes  lowered  two  or  three  degrees, 
and  varies  in  different  regions.  There  may  be  anresthesia  of  the  mucous 
membranes  of  the  mouth,  the  pharynx,  and  larynx  ;  or  the  organs  of 
special  sense  may  be  implicated,  and  a  resulting  amaurosis,  amblyopia,  or 
deafness  ensue.  In  a  paper  upon  "  Hysterical  Affections  of  the  Eye,"  by 
Dr.  Geo.  C.  Harlan,^  of  Philadelphia,  attention  is  directed  to  retinal  an- 
aesthesia and  various  hysterical  disorders  of  an  interesting  character. 

"  Almost  any  derangement  of  vision  may  be  counterfeited.  A  little  girl 
of  eight  years  complained  that  every  object  that  she  looked  at  seemed 
covered  with  diagonal  white  lines,  the  direction  of  which  she  indicated 
with  her  finger.  As  the  ophthalmoscope  revealed  a  normal  fundus,  a 
favorable  prognosis  was  given.  This  was  made  more  positive  the  next 
day,  when  the  white  lines  changed  to  blue,  and  was  justified  by  the  early 
disappearance  of  the  difficulty. 

''  In  the  second  class  of  cases  we  have  more  or  less  retinal  anaesthesia, 
with  anomalous  and  variable  symptoms,  changing,  perhaps,  at  each  ex- 
amination. 

"  In  the  third  class  of  cases  the  parts  affected  have  been  the  retina,  the 
muscle  of  accommodation,  the  external  muscles  of  the  eyeball,  and  the 
elevator  of  the  upper  eyelid. 

"  It  is  not  very  uncommon  to  meet  with  patients  who  have  apparently 
perfect  eyes  and  full  acuity  of  vision,  but  who  say  that  the  test  letters  be- 
come blurred  and  unrecognizable  after  they  have  looked  at  them  for  a  few 
seconds.  That  this  is  due  to  an  exhaustion  of  the  sensibility  of  the  retina 
which  disables  it  from  the  sustained  performance  of  its  function,  and  not 
to  an  irregular  action  of  the  accomtaodation,  is  shown  by  the  fact  that  it 
persists  when  the  eye  is  fully  under  the  effects  of  atroj^ia. 

As  to  color  blindness  in  hysterical  women,  I  think  its  importance  has 
been  exaggerated,  and  I  have  very  rarely  met  with  even  the  slightest 
affection  of  the  color-sense,  unless  the  hysteria  has  existed  in  connection 
with  cerebral  disease  and  herai  anaesthesia. 

Taste  and  smell  are  sometimes  impaired,  so  that  there  is  a  greater  or 
less  extensive  loss  or  a  perversion,  the  patient  declaring  that  natural  odors 
are  reversed,  or  that  articles  of  food  are  tasteless. 

The  Motorial  symptoms  are  numerous,  and  maybe  either  of  a  sthenic  or 
asthenic  character.  The  more  simple  include  spasms,  violent  gesticulations, 
and  contractures :  the  more  obstinate,  paralysis  of  either  a  hemiplegic, 
or  paraplegic,  or  even  a  local  form,  and  chorea  and  convulsions,  as  well  as 
various  kinds  of  muscular  incoordination.  The  individual  may  assume 
the  most  painful  positions,  the  limbs  being  rigidly  flexed  or  extended,  and 
the  face  distorted  by  grimaces  of  the  most  absurd  description.  Sometimes 
there  is  torticollis,  or  spasm  of  some  small  group  of  muscles,  or  the  muscular 

1  Phil.  Med.  and  Surg.  Eep.,  August  12,  1876. 


HYSTERIA.  459 

rigidity  may  even  amount  to  opisthotonos,  pleurothotonos,  or  emprostho- 
tonos,  and  these  forms  of  trouble  are  much  more  marked  in  conditions  of 
hystero-epilepsy  and  hystero-catalepsy.  The  dependence  of  these  motorial 
phenomena  upon  reflex  excitement  is  their  marked  feature,  slight  peri- 
pheral irritations,  uterine  trouble,  or  sexual  excitement  of  any  kind,  often 
being  the  origin  of  the  affection. 

The  pharynx,  larynx,  and  not  rarely  the  stomach  are  implicated,  so 
that  difficulty  of  swallowing,  loss  of  speech,  and  vomiting  are  resulting 
phenomena.  Hysterical  attacks  of  a  convulsive  character  are  met  with 
sometimes,  when  the  jDatient  is  apparently  unconscious,  but  is  in  reality 
not  at  all  so.  There  is  slow  respiration,  which  is  scarcely  perceptible,  and 
small  weak  pulse.  The  legs  and  arms  may  be  wildly  thrown  about,  or 
rigidly  extended,  and  there  may  be  opisthotonos,  while  the  skin  is  livid, 
and  may  be  bathed  in  perspiration.  A  lighter  grade  of  attack  is  frequently 
seen,  in  which  the  patient,  after  a  period  of  excitement,  screams,  and  falls 
to  the  floor  (being  very  careful  not  to  hurt  herself)  ;  her  muscles  become 
contracted  ;  she  breathes  heavily,  froths  at  the  mouth,  talks  incoherently, 
and  berates  those  about  her.  She  may  cry,  and  in  doing  so  sobs  violently, 
sometimes  catching  her  breath  in  an  alarming  manner,  frightening  her 
attendants  and  attracting  sympathy.  If  left  to  herself  and  not  noticed, 
she  may  fall  asleep  or  gradually  recover.  The  patient  looks  about  the 
room  during  the  attack,  and  is  undoubtedly  conscious  of  what  transpires. 
One  significant  mark  of  hysteria,  previously  alluded  to,  is  that,  however 
much  the  patient  throws  herself  about,  she  is  always  careful  not  to  do  her- 
self injury.  Pomme^  was  among  the  first  to  describe  hysterical  contrac- 
tures, and  later  Gorget  related  a  case  of  hysterical  flexion  of  the  thigh 
upon  the  pelvis  which  was  supposed  to  be  due  to  coxalgia.  In  hemiplegic 
contractures  the  upper  limb  may  be  drawn  in  to  the  trunk,  the  forearm 
is  flexed  at  a  right  angle,  the  thumb  is  bent  so  that  the  point  is  buried  in 
the  palm  of  the  hand,  and  it  is  covered  by  the  other  fingers. 

According  to  Strauss,^  extension  of  the  upper  limbs  is  quite  rare.  The 
lower  limb  is  extended,  so  that  the  foot  presents  the  appearance  of  talipes 
equiuus,  the  toes  having  a  claw-like  apj)earance.  The  thigh  is  extended 
on  the  pelvis,  and  the  whole  limb  is  adducted. 

Hysterical  contractures  of  a  permanent  character  may  affect  the  body, 
either  laterally  or  below  the  waist,  or  but  one  member  may  be  involved. 
Charcot^  relates  a  case  in  which  the  left  leg  was  firmly  extended.  The 
foot  presented  the  deformity  of  talipes  varus,  and  the  limb  was  very  rigid, 
so  that,  by  lifting  it,  the  body  could  be  moved  without  bending  the  knee. 
The  contracture  could  be  overcome  by  chloroform,  but  returned  when  its 
effects  had  disappeared.  In  this  case  the  limb  was  agitated  by  a  tremor, 
or  "  tremulation  convulsive,"  as  this  author  calls  the  movement.  These 
hysterical  contractures  often  last  for  years,  and  are  cured  spontaneously. 
Skey  *  relates  a  case  which  is  quite  interesting. 

^  Traits  des  Affections  Vaporeuses.  '■^  Op.  cit.,  p.  307. 

*  Des  Contractures,  Paris,  1875.  *  Hysteria,  etc,  London,  1866. 


460  CEREBRO-8PINAL    DISEASES. 

"  In  the  year  1864  a  young  lady  of  16  years  of  age  was  placed  under 
my  care  under  the  following  circumstances :  For  eight  months  prior  to 
her  visit  to  me,  she  had  been  suffering  from  inversion  of  the  left  foot, 
which  was  so  twisted  as  to  bring  the  point  of  the  foot  to  the  opposite 
ankle  ;  in  fact,  at  nearly  a  right  angle  with  the  foot  of  the  opposite  side. 
Her  family  consulted  a  surgeon  of  much  experience  in  the  treatment  of 
distortion,  and  of  orthopaedic  notoriety.  The  case  was  considered  as  an 
example  of  an  ordinary  distortion,  and  the  foot  was  placed  in  a  very  ela- 
borately made  foot-splint,  by  the  force  of  which  it  was  made  to  approach 
a  parallel  relation  to  the  opposite  side  ;  but  it  was  an  approach  only,  for 
no  mechanism  could  retain  it  in  a  perfect  position,  the  toes  yet  to  some 
degree  pointing  inwards.  A  month  elapsed,  and  the  disease  continued 
unchanged.  A  second  orthopaedic  authority  was  then  consulted  in  con- 
junction with  the  first,  and  as  no  new  light  was  thrown  on  the  disease  by 
the  combined  opinions  of  the  two,  the  same  principle  of  treatment  was 
recommended  to  be  continued,  and  the  mechanism  was  yet  somewhat 
more  elaborated,  and  thus  the  eighth  month  of  the  young  lady's  life  passed 
away,  during  which  no  constitutional  treatment  was  resorted  to,  and  loss 
of  exercise,  for  she  walked,  it  was  almost  unnecessary  to  say,  with  great 
difficulty." 

Skey  examined  the  foot,  and  arrived  at  the  conclusion  that  the  inver- 
sion was  too  great  to  be  due  to  the  muscles  alone,  and  discovered  that 
those  of  the  whole  limb  were  involved  ;  that  the  disease  had  appeared 
suddenly  in  a  girl  of  15  years,  who  was  otherwise  well  and  strong,  and  in 
whom  there  was  no  indication  of  acute  local  disease. 

The  apparatus  was  removed  ;  a  hearty  diet,  with  tonics,  was  ordered  ; 
she  was  told  to  walk ;  and  at  the  end  of  six  months  was  invited  to  a  ball, 
her  foot  being  still  deformed.  She  accepted  an  invitation  to  dance,  and 
remained  standing  throughout  the  entire  evening.  She  had  been  sud- 
denly cured. 

Hemiplegia  and  paraplegia  of  an  hysterical  character  are  sometimes 
met  with,  as  well  as  local  paralysis,  but  the  face  is  rarely  affected  in 
hysterical  hemiparesis,  and  the  tongue  never  so. 

The  walk  is  quite  different  from  that  of  organic  hemiplegia,  and 
the  foot  is  simply  dragged  along  and  not  swung,  and  there  is  an 
absence  of  that  helplessness  which  is  so  characteristic  of  the  seri- 
ous trouble.  Electric  sensibility  and  contractility  are  not  usually 
affected,  though  the  former  may  be  occasionally  impaired.  The  cure  is 
spontaneous,  and  there  is  never  atrophy  or  anj'^  of  the  peculiar  tissue 
changes  of  neuritis  which  generally  follow  hemiplegia  from  cerebral  dis- 
eases. Paraplegia  of  the  hysterical  variety  is  rarely  attended  by  any 
urinary  or  rectal  trouble,  and  never  by  incontinence,  and  the  muscles  are 
well  nourished  and  respond  to  electric  stimulation.  Some  voluntary 
motion  is  possible  in  the  recumbent  position,  and  it  is  only  when  the 
patient  walks  that  she  shows  her  loss  of  power.  Reynolds  states  that  a 
peculiarity  of  the  disease,  which  is  familiar  to  all,  is  the  fact  that  no 
amount  of  help  can  keep  the  patient  from  staggering  or  falling ;  she  may 
be  supported  by  strong  anus,  but  she  sinks  to  the  ground,  not,  however, 
falling  entirely,  but  regaining  her  position  by  a  voluntary  effort. 

The  patellar  tendon-reflex  is  usually  increased  upon    the  paralyzed 


HYSTERIA.  461 

side  ill  hysterical  hemiplegia.  I  have  never  found  it  to  be  diminished,  but 
care  should  be  taken  to  define  the  line  between  the  paralysis,  due  to 
ravelitis,  with  hysterical  symptoms,  and  the  hysteria,  in  which  there  is 
paralysis.     I  have  referred  to  the  former  cases  in  a  previous  article. 

The  visceral  troubles  are  a  host  in  themselves.  Not  only  may  the 
patient  complain  of  unbearable  pains  situated  in  the  liver,  stomach,  and 
other  organs,  but  there  may  be  urinary  affections  of  considerable  impor- 
tance. Two  varieties  of  hysterical  urinary  derangement  are  spoken  of 
by  Charcot,  one  beiug  ischuria,  and  the  other  a  complete  suppression, 
which  he  has  called  oligurie.  In  both  cases  the  urinary  passages  are  per- 
fectly normal ;  in  the  first  there  is  simple  retention  of  urine  in  the 
bladder ;  and  for  a  long  time  (amounting  even  to  months  or  years)  it  will 
be  found  necessary  to  use  a  catheter. 

Laycock^  has  called  attention  to  this  state  of  afiairs,  which  lasts  some- 
times twenty-four  or  thirty-six  hours,  during  the  menstrual  epoch. 
Charcot  has  found  the  condition  to  last  even  longer— sometimes  for  seve- 
ral days.  This  suppression  of  urine  is  occasionally  accompanied  by 
vomiting,  and  the  presence  of  urea  has  actually  been  discovered  in  the 
vomited  substances.  This  has  been  explained  by  the  experiment  of 
Brown-Secjuard,  w^ho  found  that  after  certain  forms  of  mutilation  cai*- 
bonate  of  ammonia  or  free  urea  was  found  in  the  intestines  of  animals, 
which  settled  the  fact  that  there  was  a  "  supplementary  elimination." 
This  same  condition  of  afiairs  is  not  unusual  in  renal  disease,  and  the 
odor  of  the  breath  and  sweat  is  decidedly  uriniferous.  Vomiting  of  fecal 
matter  is  a  rare  symptom.  There  is  in  the  majority  of  cases  a  decided 
increase  in  the  amount  of  urine  voided.  It  is  of  a  very  light  color,  quite 
limpid,  and  of  low  specific  gravity,  and  is  sometimes  discharged  during 
the  convulsive  seizure.  Digestive  disturbances,  accompanied  by  eructa- 
tions of  wind,  borborygmi,  epigastric  pain,  and  loss  of  appetite,  are  pre- 
sent in  most  cases. 

Abstinence  from  food  and  continued  unconsciousness  need  hardly  be 
alluded  to  in  this  chapter.  Cases  of  this  kind  derive  sensational  impor- 
tance from  newspaper  description,  and  from  their  very  hysterical  nature 
suggest  fraud  and  deception.  The  case  of  Louise  Lateau,  as  well  as 
others,  has  been  cleverly  investigated,  and  is  doubtless  familiar  to  my 
readers.  The  history  of  this  class  of  cases  furnishes  us  with  many  exam- 
ples, some  of  which  are  quite  ancient. 

Senneratus^  writes  of  three  individuals  who  fasted  almost  two  years, 
and  "  yet,  though  lean,  were  in  good  health." 

Upon  the  authority  of  Schenck,^  we  are  informed  that  "Katherine 
Binder,  a  native  of  the  upper  Palatinate  in  Germany,  was  said  to  receive 
no  other  nourishment  than  air  for  more  than  nine  years.  John  Caffimer, 
in  the  year  of  our  Lord  1585,  commanded  her  to  be  watched  by  a  Minis- 
ter of  State,  Ecclesiastic  and  two  Licentiates  in  Physic,  but  they  could 

1  Treatise  on  the  Xervous  Diseases  of  Women,  London,  1340,  p.  229. 

2  Prax  Med.,  p.  212.  ^  Obs.  1.  3,  p.  306. 


462  CEREBRO-SPINAL    DISEASES. 

make  no  discovery  of  her  beiug  an  impostor,  and  therefore  reported  it  to 
be  miraculous." 

A  symptom  which  I  am  inclined  to  think  very  common,  but  which  is 
not  generally  considered  so,  is  the  globus  hystericus.  The  patient  calls  at- 
tention to  a  "  lump  which  rises  in  her  throat."  It  is  probably  nothing 
more  than  a  spasmodic  contraction  of  the  muscles  of  the  pharynx  or  oeso- 
phagus, or  in  other  cases  a  morbid,  sensory  distui'bance.  It  "  rises  "  from 
the  epigastrium,  and  is  attended  by  dyspnoea  and  difficulty  in  deglutition. 
In  some  cases  obstinate  vomiting,  which  is  readily  excited  by  such  slight 
agencies  as  a  hand  laid  upon  the  surface  of  the  body,  or  the  administra- 
tion of  a  very  small  amount  of  food,  is  a  formidable  symptom,  and  unless 
corrected  the  patient  may  become  speedily  exhausted.  In  one  case  which 
I  saw  at  the  request  of  Dr.  Austin  Flint,  this  condition  had  lasted  for  seve- 
ral years,  and  was  not  relieved  by  any  medication,  but  was  for  a  time 
stopped  by  pressure  made  over  the  left  ovary. 

The  disease  among  males  is  of  interest  because  of  its  rarity.  A  case 
presented  by  Bonnemaison,'  of  Toulouse,  may  be  cited : — 

The  patient  was  a  man  aged  72.  The  brother  of  the  patient  was  a 
hypochondriac;  and  his  mother,  who  died  at  the  age  of  81,  suffered  from 
various  forms  of  nervous  disturbance,  analogous  to  those  of  her  hysterical 
son,  after  reaching  her  76th  year.  The  attacks  in  the  case  of  Dr.  Bonne- 
maison's  patient  came  on  three  or  four  times  in  the  twenty-four  hours  ; 
ushered  in,  when  occurring  during  the  night,  by  nightmare;  when  in  the 
day,  by  various  sensations,  and  usually  by  pain  in  the  ei^igastric  region. 
An  aura  proceeding  from  this  point  traveled  along  the  sternum  to  the 
throat,  and  thence  to  the  mouth  and  tongue,  and  other  regions  of  the 
body,  the  muscles  of  the  parts  affected  by  this  sensation  being  thrown  into 
violent,  rapid,  and  unaccountable  convulsive  action.  The  patient  uttered 
strange  cries  and  yells,  or  repeated  the  same  words  over  and  over  again 
with  extreme  rapidity.  At  times  the  tongue  would  be  smacked  violently 
against  the  roof  of  the  mouth,  the  cheeks  spasmodically  puffed  out  with 
the  action  of  blowing  or  whistling,  and  the  jaws  snapped  violently  toge- 
ther, without,  however,  biting  the  tongue.  The  arms  were  moved  rhythmi- 
cally together  with  the  action  of  flying,  or  drumming,  or  playing  the 
piano.  Sometimes  the  lower  limbs  shook  violently,  or  executed  the 
movements  of  dancing.  The  attacks  bore  a  strong  resemblance  to  those 
of  the  "  convulsionnaires  "  of  St.  Medard,  or  the  rhythmic  chorea  of  the 
epidemics  of  Louviers,  Toulouse,  and  Morziac.  The  disturbance  of  the 
voluntary  muscles  might  be  accompanied  by  spasm  of  the  involuntary 
mu-cles  also,  or  the  latter  might  form  the  chief  phenomena  of  the  parox- 
ysm, consisting  in  hiccup,  eructations,  sighs,  and  borborygmi.  During 
the  whole  of  the  attack  the  hyperiesthesia  of  the  skin  was  excessive, 
especially  at  the  forehead,  epigastric  region,  and  sternum  ;  there  was  no 
loss  of  consciousness.  The  attack  ended  either  wi^h  a  copious  flow  of 
limpid  urine,  or  a  discharge  of  tears.  There  was  never  any  pain  or 
sensation  referable  to  the  generative  organs,  nor  anything  whatever  in 
the  history  of  the  symptoms  indicative  of  their  implication  in  any  way 
whatever.     The  same  absence  of  any  pathological  condition  of  the  organs 

^  Archives  Generales  de  M6d.,  Jan.,  1875.    Abst.  in  Med.  News,  Oct.  1875. 


HYSTERIA.  463 

of  generation  has  been  observed  in  cases  of  male  hysteria  observed  by 
others. 

Children  are  not  exempt  from  hysterical  troubles,  and  much  of  the 
perversity  of  young  children  will  often  be  found  to  be  of  this  character. 
If  this  fact  was  recognized,  a  great  deal  of  the  suffering  in  after  life 
might  be  prevented. 

Many  of  Briquet's  cases  began  before  the  twelfth  year,  and  it  will  ba 
found  that  even  before  puberty  the  tendency  to  this  trouble  may  be  often 
recognized. 

Dr.  Jacobi,^  whose  careful  investigations  of  the  nervous  diseases  of  young 
children  have  furnished  us  with  striking  facts,  looks  upon  hysteria  as  an 
extremely  common  trouble  among  young  children,  connected  often  with 
masturbation  even  in  infants  of  two  or  three  years.  Jacobi  refers  to  the 
tables  of  Briquet,  Amann,  and  others,  to  show  that  hysteria  is  found 
frequently  before  adolescence.  Of  Amann's  cases,  16  of  268  cases  were 
between  8  and  10  years;  of  those  of  Althaus — 820 — seventy-one  were  be- 
fore the  tenth  year.  Landouzy  collected  303  cases,  48  of  whom  were 
between  the  tenth  and  fifteenth  years. 

Causes. — Hysteria  is  most  decidedly  an  affection  of  women,  and  is 
connected  in  many  instances  with  some  sexual  or  uterine  derangement. 
Among  men  hysteria  is  far  le«s  rare,  I  think,  than  it  is  supposed  to  be, 
but  with  them  the  hysterical  trouble  is  of  a  lighter  grade,  and  it  is  un- 
usual for  examples  either  of  ansesthesia,  convulsions,  or  contractures  to  be 
witnessed.  As  a  rule,  the  hysterical  man  possesses  a  smooth  face,  slen- 
der figure,  soft  falsetto  voice,  large  thyroid  cartilages,  small  hands,  and 
tapering  fingers,  and  sometimes  large  mammse.  His  genital  organs  are 
poorly  developed,  and  his  manners  are  mincing  and  effeminate.  Hysteri- 
cal phenomena  are,  however,  not  uncommonly  presented  by  stalwart  men. 
Among  women  this  approach  to  the  appearance  and  behavior  of  the  other 
sex  is  inconsistent  with  the  development  of  hysteria.  Women  with  bushy 
eyebrows,  coarse  hair,  perhaps  a  slight  moustache,  angular  build,  narrow 
hips,  and  coarse  voices  are  seldom  hysterical.  They  are  "  strong-minded," 
rarely  emotional,  and  inclined  to  look  upon  the  hysterical  trouble  of  their 
weak  sisters  with  something  like  contempt. 

Reynolds  aptly  says :  "  Some  women  are  as  little  likely  to  become 
hysterical  as  some  men  are  to  fall  pregnant."  It  might  be  added  :  and 
as  their  chances  to  conceive  are  diminished.  Hysteria  is  of  much  more 
common  appearance  among  spinsters  and  single  women,  and  is  far  from 
being  rare  among  old  maids  who  marry  late  in  life.  A  case  of  this  kind 
fell  under  my  observation  some  years  ago.  An  examination  revealed  an 
undeveloped  uterus ;  and  from  the  nuptial  night  dated  a  series  of  ner- 
vous symptoms  of  a  grave  hysterical  character.  The  uterine  irritability 
which  is  connected  with  the  pregnant  state  between  the  ages  of  thirty  and 

1  On  Masturbation  and  Hysteria  in  Young  Children,  by  A.  Jacobi.  Am.  Jour,  of 
Obstetrics,  etc.,  vols.  viii.  and  ix.,  1876. 


464  CEREBRO-SPIKAL    DISEASES. 

forty  is  apt  to  produce  a  profound  impression  upon  the  nervous  system. 
Among  married  women  with  impotent  mates,  or  among  tliose  who 
have,  on  the  other  hand,  suffered  through  the  lust,  inconsideration,  and 
brutalitv  of  husbands  of  another  kind,  the  disease  is  not  uncommon.  The 
puerperal  state,  lactation,  and  the  cessation  of  the  catamenia  favor  its 
development. 

I  have  lately  treated  a  number  of  cases  of  a  class  which  I  am  sure  is 
familiar  to  most  medical  men,  especially  to  those  who  devote  the  greater 
part  of  their  time  to  the  study  of  nervous  disease.  I  allude  to  certain 
ill-defined  hysterical  conditions  that  are  connected  with  or  follow  the  pu- 
erperal state.  These  cases  do  not  come  under  the  head  of  puerperal 
mania,  which  is  a  common  and  well-recognized  form  of  insanity,  but  are 
difficult  of  description  and  classification,  because  of  their  irregularity. 
The  patients  I  have  seen  have  all  been  urcemic  at  some  time  during  preg- 
nancy, not  to  the  extent  which  is  accompanied  by  convulsions  or  other 
grave  symptoms,  but  the  blood-poisoning  was  much  more  extensive  than 
it  usually  is.  Barker  thinks  that  albuminuria  is  not  the  cause  of  puerpe- 
ral mania,  but,  when  found,  is  merely  a  coincidence.  In  the  cases  I  allude 
to  it  was  always  present,  and  seemed  to  be  the  cause.  I  have  seen  the 
same  symptoms  expressed,  though  in  a  less  marked  degree,  in  patients 
who  were  suffering  from  chronic  nephritis,  and  where  the  puerperal  state 
had  nothing  to  do  with  the  history.* 

In  the  spring  of  1875  Mrs.  C  came  to  my  office  with  her  husband.  I 
found  her  to  be  an  amiable,  well-educated  woman  of  thirty-two  years  of 
age  ;  her  manner  was  cheery  and  agreeable,  and  there  was  no  evidence  of 
mental  trouble.  Three  months  before  this  she  had  been  delivered  of  a 
child  at  full  term,  which  was  born  dead.  X.  week  after  her  milk  "  dried 
up."  The  last  months  of  her  pregnancy  were  attended  by  evidences  of 
urtemia,  marked  ana-sarca,  clouded  urine  excreted  in  small  quantity,  but 
no  convulsions  or  mania.  Mrs.  C.'s  previous  history  was  uneventful. 
There  was  absolutely  no  hereditary  predisposition  to  insanity,  and  her 
mind  was  perfectly  clear  during  pregnancy. 

She  was  antemic,  and  complained  of  dizziness,  palpitation,  gastric  dis- 
turbance, vertical  headache,  loss  of  memory,  ringing  in  the  ears,  etc.  She 
passed  her  urine  at  the  time  of  her  visit  in  normal  amounts,  and  it  did  not 
contain  albumen.  Her  complexion  was  pale,  and  her  pupils  were  dilated. 
A  very  slight  blueness  of  the  skin  was  apparent,  but  was  confined  to  the 
hands.  The  lips  had  not  lost  their  lines  of  expression,  which  is  generally 
the  case  in  melancholia,  and  they  were  not  swollen.  She  was  inclined  to 
sleep.  Considering  that  the  symptoms  indicated  '•  cerebral  ansemia,"  I 
began  with  iron,  phos^^horus,  and  other  remedies  of  the  same  kind. 

Two  days  after  this  visit  she  again  appeared  at  my  office,  looking  much 
agitated,  and  saying  that  she  had  come  for  "  protection  from  herself." 
She  had  been  tempted  to  get  up  from  her  bed  and  cut  her  throat  with  her 
husi)and's  razors.  She  was  perfectly  cognizant  of  her  condition,  and  was 
aware  of  the  fearful  nature  of  the  act  she  was  tempted  to  perform.  After 
a  talk  of  half  an  hour,  she  left  me,  feeling  settled,  and  without  the  desire. 

^  Bost<'n  Med.  and  Surg.  Journ.,  June  15,  1876. 


HYSTERIA.  465 

On  another  occasion  she  came  to  see  me,  as  "she  had  the  feeling  again." 
She  had  taken  her  sister's  baby  in  her  lap,  and  while  it  was  there  she 
''suddenly  felt  like  throwing  it  on  the  floor"  with  all  her  force.  At 
another  time  she  was  prompted  to  run  the  blade  of  a  pair  of  scissors  into 
the  fontanelle.  These  impulses  would  recur  every  week  or  so,  when  she 
always  came  to  see  me,  and  would  sit  a  few  minutes,  talk  upon  other  sub- 
jects, and  rise  to  go,  saying  :  "  Now,  doctor,  the  feeling  has  passed  off" 
Not  at  this  time,  nor  at  any  other,  were  there  delusions  of  any  kind. 
Under  treatment  she  improved  in  general  health,  and  her  nervous  symp- 
toms disappeared. 

Her  last  morbid  impulse  occurred  during  the  fourth  month  after  treat- 
ment. One  evening,  with  her  husband  and  brother,  she  went  upon  the 
house-top  to  see  a  fire.  While  there  the  old  feeling  returned,  and  she 
would  have  thrown  herself  from  the  roof,  had  she  not  been  prevented. 
This  was  the  last  and  most  serious  expression  of  the  disease.  Since  that, 
time  she  has  not  had  a  return,  and  says  she  is  perfectly  well. 

A  second  case  I  lately  saw  was  attended  by  slight  though  perfectly  de- 
fined mental  changes.  The  patient  was  a  young  married  woman  of 
twenty-four  years.  For  some  time  before  parturition  and  during  her 
pregnancy  there  was  kidney  trouble.  Before  her  labor  she  was  a  loving 
and  devoted  wife,  but  shortly  after  lost  all  of  her  amiability,  and  treated 
her  husband  and  mother  with  marked  coolness,  and  sometimes  with  de- 
cided rudeness.  A  month  after  delivery  she  took  a  deep  interest  in  re- 
ligious matters,  and  carried  the  observance  of  her  religious  duties  to  such 
a  pass  as  to  be  disagreeable  to  all  about  her.  She  did  eccentric  things, 
such  as  getting  up  at  night,  going  down  to  the  piano  in  the  drawing-room, 
and  singing  hymns.  When  reminded  of  the  unseasonableness  of  the  hour, 
she  would  return  to  her  bed,  first  shutting  the  hymn-book  in  a  mechanical 
manner. 

I  saw  her  in  this  condition,  and  found  a  state  closely  bordering  on  mel- 
ancholia, though  there  was  no  mental  depression,  no  anxious  facies,  no 
sighing,  no  hopelessness.  A  p^^rsistent  use  of  agents  which  would  restore 
the  action  of  the  kidneys,  combined  with  fresh  air  and  a  well-regulated 
diet,  did  her  much  good.  After  a  few  weeks  the  patient  slept  well,  and 
the  mental  irritability  gradually  disaj^peared. 

In  both  of  these  cases  there  were  symptoms  which  were  not  those  of 
insanity.  In  Case  I.  the  patient  was  able  to  reason,  and  had  full  con- 
sciousness of  her  infirmity ;  so  that  she  had  the  power  to  seek  the  society 
of  others  when  she  felt  the  impulse.  There  was  the  absence  of  all  physi- 
cal signs  of  insanity,  except  the  coloration  of  the  skin.  In  the  second 
case,  the  short  duration  of  the  mental  trouble,  and  its  subsidence  with 
improvement  of  the  kidney  difficulty,  proved  it  to  be  a  functional  de- 
rangement. 

As  regards  age,  pronounced  hysteria  rarely  begins  before  the  twelfth 
year;  it  generally  takes  its  origin  at  the  time  of  puberty,  and  from  this  pe- 
riod may  continue  through  life.  It  not  rarely  begins  after  marriage,  or 
sometimes  not  until  after  the  menopause,  but  this  is  exceptional.  In  males 
it  begins  in  middle  life,  though  I  have  seen  the  affection  among  boys.  Hys- 
teria is  not  necessarily  a  disease  of  the  well-to-do,  though  indolent  habits  and 
luxurious  living  favor  its  development ;  but  it  frequently  appears  among 
30 


466  CEREBRO-SPINAL    DISEASES. 

overworked  shop-girls  who  are  compelled  to  stand  for  many  hours  during 
the  day.  The  follies  of  fashionable  life  have  much  to  do  with  the  pro- 
duction of  a  morbid  performance  of  functions  of  the  nervous  system. 
Continued  rounds  of  dissipation,  parties  and  balls  which  do  away  with 
sleep,  together  with  excitement  and  late  suppers,  days  of  idleness  spent  in 
reading  sensational  novels  and  eating  improper  food,  or  tippling  liqueurs, 
especially  favor  the  development  of  this  morbid  state.  This  mode  of  life, 
when  kept  up  for  some  time,  especially  when  the  menstrual  periods  are 
disregarded,  brings  about  a  condition  of  ei'ethism  which  expresses  itself 
in  the  symptoms  I  have  named.  Dysmenorrhoea  may  be  attended  by 
attacks,  and  so  may  menorrhagia,  but  many  cases  occur  even  when  there 
is  no  disturbance  of  menstrual  function.  Abnormalities  of  the  posi- 
tion of  the  uterus,  and  excessive  sexual  excitement,  whether  from  mas- 
turbation or  coition,  have  decided  etiological  bearing,  while  warm 
weather  favors  the  development  of  attacks.  Mental  worry,  emotional 
excitement,  an  attack  of  illness,  and  a  number  of  influences  of  the  same 
kind  all  act  as  exciting  causes. 

Morbid  Anatomy  and  Pathology. — Accidental  lesions  are  some- 
times found,  but  so  irregular  is  their  character  that  they  are  valueless  as 
indications. 

As  to  the  pathology  of  the  affection,  very  little  can  be  said  in  addition 
to  what  has  already  been  stated  in  speaking  of  the  symptoms.  Hysteria 
may  be  said  to  be  a  very  near  relation  to  insanity,  and  one  writer  even  con- 
siders it  a  form  of  insanity ;  but  I  should  be  loath  to  believe  that  so  many 
people  are  actually  insane.  Hysteria  is  rather  a  mental  inco-ordinatiou. 
Emotional  exaltation,  conuected  with  liveliness  of  ideation  and  with 
feeble  volition,  and  a,  paralysis  of  judgment,  may  be  said  to  be  the  mental 
condition  of  an  hysterical  patient.  The  balance  is  lost ;  and  when  the 
emotional  side  has  full  play,  all  the  reflex  and  sensational  functions  are 
active  and  unchecked,  while  it  is  only  with  difliculty  that  the  governing 
side  to  which  belong  volitional  and  intellectual  control  is  made  to  counter- 
act the  other.  This  is  only  brought  about  by  the  most  powerful  agencies, 
and  sometimes  these  are  inefficient.  If  the  reader  will  consult  an  article 
by  Lauder  Brunton,^  in  one  of  the  West  Riding  Reports,  he  will  find 
some  excellent  diagrams  which  illustrate  the  mechanism  of  the  nervous 
centres  in  the  physiology  of  inhibition. 

I  have  slightly  modified  the  chart  of  this  author  by  introducing  another 
centre.  Let  Fig.  60  represent  the  arrangement  of  nerve  centres  concerned 
in  the  performance  of  the  functions  of  the  cerebro-spinal  system.  I.  indi- 
cates the  centre  of  ideation,  E.  an  emotional  centre,  W.  a  will  centre,  M. 
a  motor  centre  innervating ;  M  (a  muscle),  v  (a  vessel),  and  G  (a  gland). 
S.  is  a  sensory  centre,  and  P.  the  origin  of  an  external  impression.  The 
connecting  lines  are  efferent  and  afferent  nerves.  It  will  be  seen  that  I  is 
in  centrifugal  communication  with  W,  with  M,  S,  and  with  E.  So  that 
ideas  which  are  evolved  without  external  stimulus  may  find  motor  expres- 

^  West  Riding  Lunatic  Asylum  Reports,  vol.  iv.  p.  179. 


HYSTERIA. 


467 


sion  either  in  a  voluntary  or  involuntary  manner  ;  may  affect  the  emo- 
tional centre,  or  may  be  stimulated  by  impressions  received  either  from 
that  centre  or  from  S.  External  impressions  may  be  transmitted  from  P 
either  to  S,  to  E,  or  to  M ;  in  one  case  being  perceived  and  transmitted 
to  a  higher  centre,  or  being  converted  into  a  reflex  action.  E  is  affected 
by  S  and  by  I,  and  in  turn  influences  M  and  I,  and  to  a  slight  degree  W  ; 
or  on  the  other  hand  may  be  controlled  by  W.  In  the  normal  state  we 
may  roughly  suppose  the  proportions  of  these  areas  to  be  represented  in 
the  right-hand  diagram.  In  the  hysterical  state  their  relative  (left-hand 
diagram)  size  is  greatly  altered ;  E  gains  in  size,  and  W  is  very  much 
diminished.  The  relative  size  of  the  communicating  tracts  also  under- 
goes modification.  Though  this  explanation  is  decidedly  rough  and  super- 
ficial, I  trust  it  will  give  the  reader  a  better  idea  of  the  pathology  of  this 
affection  than  would  any  extended  written  description. 


Fig.  60. 


The  Pathology  of  Hysteria. 

Diagnosis. — As  hysteria  may  counterfeit  nearly  every  known  symptom, 
it  will  be  seen  that  the  task  of  making  a  diagnosis  is  not  always  an  easy 
matter.  If,  however,  we  consider  that  the  symptoms  are  generally  presented 
in  a  group,  which  is  decidedly  irregular  and  its  elements  inharmonious,  and 
that  the  patient  is  on  the  alert  in  regard  to  all  that  goes  on  about  her ; 
that  she  has  a  fear  of  severe  treatment ;  that  the  use  of  chloroform  will 
certainly  overcome  the  contractures ;  and  that  the  cure  is  generally  sudden, 
there  is  not  much  chance  for  mistake.  Besides,  there  is  never  any  evidence 
of  gross  organic  change,  the  muscles  only  losing  their  fulness  from  inaction. 
Jannet^  says  that  the  difference  between  hysteria  and  epilepsy,  with 
which  it  is  often  confounded,  can  be  detected  by  the  thermometer,  there 
being  no  change  in  the  former  trouble. 


^  De  r  hyslerie  chez  1'  homme,  Thise  de  Paris,  1880. 


468  CEREBRO-SPINAL    DISEASES. 

Prognosis. — If  the  individaal  has  suffered  for  a  great  length  of  time, 
and  especially  if  there  be  confirmed  uterine  or  ovarian  disease,  the  chances  of 
entire  recovery  will  be  extremely  bad.  The  disease  is  not  only  discouraging 
in  the  way  of  treatment,  but  annoying  to  the  friends,  and  far  more  disa- 
greeable to  the  physician,  who  receives  very  little  for  his  pains  but  abuse 
and  want  of  appreciation.  Some  cases  may  be  easily  cured,  and  these 
are  among  young  people.  Much,  however,  depends  upon  treatment.  Dr. 
Mitchell  has  known  of  three  deaths  from  hysteria,  and  all  three  were 
abrupt,  and  one  was  due  to  acute  congestion  of  the  kidneys.  In  two 
cases  that  have  fallen  under  my  notice,  death  has  taken  place  in  an  en- 
tirely unexpected  way.  In  one  patient  there  was  intense  cerebral  cedema, 
and  the  other,  seen  by  Dr.  Ball  at  my  request,  rapidly  developed 
uraemic  symptoms  and  died  comatose,  her  death  being  preceded  a  few 
hours  by  hemiplegia. 

Treatment. — The  history  of  the  treatment  of  hysteria  is  curious  in 
the  extreme.  Going  back  to  the  middle  ages  we  find  numerous  examples 
of  miraculous  cures,  which  were  undoubtedly  of  an  hysterical  character. 
Scheie  de  Vere,  in  his  little  work  entitled  "  Modern  Magic,"  thus  speaks 
of  a  favorite  mode  of  treatment  which  has  been  followed  by  the  Zouave 
Jacob  and  many  others  in  modern  times  : — 

"  The  imposition  of  hands  for  the  purpose  of  performing  miraculous 
cures  has  been  practised  from  time  immemorial ;  Chaldees  and  Brahmins 
alike  using  it  in  cases  of  malignant  disease.  The  kings  of  England  and 
of  France,  and  even  the  counts  of  Hapsburg  in  Germany,  have  been 
reputed  to  be  able  to  cure  goitres  by  the  touch  of  their  hands.  The  idea 
seems  to  have  originated  in  the  high  North,  King  Olave  the  Saint  being 
reported  by  Snorre  Sturlesou  as  having  performed  the  ceremony.  From 
thence,  no  doubt,  it  was  carried  to  England,  where  the  Confessor  seems 
to  have  been  the  first  to  cure  goitres." 

"  In  more  recent  times  a  prince,  Hohenlohe,  in  Germany,  claimed  to 
have  performed  many  miraculous  cures,  beginning  with  Princess  Schwar- 
zenberg,  whom  he  commanded  in  the  name  of  Christ  to  be  well  again. 
Many  of  his  patients,  however,  were  only  cured  for  the  moment.  When 
their  faith,  excited  to  the  utmost,  cooled  down  again,  their  infirmities 
returned.  Still  there  remain  facts  enough  in  his  life  to  establish  the 
marvellous  power  of  his  strong  wnll,  when  brought  to  bear  upon  peculiarly 
receptive  imaginations  and  aided  by  earnest  prayer." 

Several  years  ago  an  individual  named  Newton  went  about  the  country. 
It  was  his  custom  to  hire  a  large  hall  and  extensively  advertise.  Upon 
the  day  appointed  he  would  meet  the  lame,  halt,  and  blind,  and  after 
powerful  exhortations  and  prayers,  tell  them  to  form  in  line  and  pass  one 
by  one  before  him.  The  emotional  excitement  and  eager  anticipation 
were  sufiicient  in  some  instances  to  divert  the  hysterical  patients  who 
chanced  to  be  among  the  number,  so  that  in  many  instances  there  were 
spontaneous  cures,  the  lame  dropping  their  crutches,  and  starting  off  at  a 
lively  gait,  and  the  blind  recovering  their  sight. 

Beard,  in   a    paper    upon    "Mental    Therapeutics,"    recently  called 


HYSTERIA.  469 

attention  to  some  experiments  he  had  been  making.  In  many  in- 
stances of  functional  disease,  he  assured  the  patients  that  their 
recovery  would  take  place  in  some  very  short  time,  and  found  that  at  the 
time  specified  they  returned  completely  cured.  This  procedure  in  cases 
of  hysteria  is  of  great  value.  I  have  repeatedly  stopped  an  hysterical 
attack  by  a  douche  of  cold  water  or  by  the  exhibition  of  the  cautery. 
Oftentimes,  after  the  patient  has  been  pleaded  with,  threatened,  and 
dosed  to  no  effect,  a  sudden  fright  or  a  sharp  word  or  two  will  do  more 
for  her  than  anything  else  ;  but  the  physician's  demeanor  to  his  patient 
should  always  be  characterized  by  firmness  and  dignity,  and  not  by  harsh- 
ness or  undue  severity. 

It  is  a  difficult  matter  to  meet  the  peculiar  manifestation  of  disordered 
mental  expression  in  hysteria,  for,  as  we  all  know,  its  phases  are  nume- 
rous. No  two  cases  of  hysteria  are  exactly  alike,  and  consequently  no 
two  can  be  treated  in  the  same  way.  A  scolding  occasionally  does  good, 
as  I  have  just  said ;  but  in  other  cases  it  would  aggravate  the  patient's 
condition.  We  cannot  treat  the  hysterical  woman  in  a  trouble-saving 
and  careless  way  ;  and  though  many  medical  men  hold  that  a  sharp  word 
or  the  direct  appeal  to  the  common  sense,  which  is,  however,  absent  here, 
is  all  that  is  required,  it  will  be  found  that  such  a  course  is  by  no  means 
a  wise  one  to  always  follow.  In  many  cases  it  is  not  best  to  tell  the  woman 
that  she  is  "  not  to  give  way,"  or  that  she  is  "  not  to  disgrace  herself,"  for 
she  is  unable  at  once  to  use  her  will  to  overcome  all  the  indirect  agencies 
at  work  which  are  acting  upon  her  disordered  brain.  It  is  better  to  gain 
her  confidence,  and  make  her  gradually  exert  her  will  in  new  channels 
by  the  performance  of  some  act  which  requires  the  use  of  physical  force, 
and  this  form  of  exercise  may  be  prescribed  by  the  physician. 

As  to  medication,  we  may  make  use  of  the  motor-depressants,  bromide 
of  sodium,  hyoscyamus ;  or  the  mono-bromide  of  camphor  in  doses  of  three 
grains  every  hour,  till  quiet  is  obtained ;  the  spts.  etheris  co.,  chloroform 
or  chloral,  and  valerian,  or  its  compound,  valerianate  of  zinc.  The  ob- 
stinate vomiting  is  occasionally  stopped  by  hypodermic  injections  of  mor- 
phine ;  and  a  belladonna  plaster  over  the  irritable  ovary  will  often  prove 
to  be  an  excellent  form  of  treatment.  All  sources  of  reflex  irritation 
should  be  removed  as  soon  as  possible,  and  uterine  congestion  overcome 
by  leeching  the  cervix  uteri,  or  hot  douches.  When  there  is  much  irrita- 
bility of  the  pelvic  organs,  I  would  suggest  a  combination  of  tr.  cannabis 
indicus,  and  bromide  of  ammonia,  with  mucilage  as  a  menstruum. 

For  the  anaesthesia  and  paralysis,  strychnia  and  electricity  are  the  best 
remedies  of  which  I  know,  the  latter  being  employed  in  its  induced  form, 
and  the  electric  brush  applied  upon  a  dry  surface.  General  treatment  of 
a  tonic  character  should  be  used  when  it  is  possible ;  and  iron,  in  com- 
bination with  phosphorus  or  phosphoric  acid,  cod-liver  oil,  and  sea-baths, 
together  with  local  treatment.  Local  disease  should  be  promptly  eradi- 
cated if  possible,  uterine  versions  or  flexions  righted,  and  the  menstrual 
function  restored  to  its  regular  character.  In  those  bed-ridden  cases 
which  are  so  discouraging  and  trying,  we  may  use  Weir  Mitchell's  treat- 


470  CEREBRO-8PINAL    DISEASES. 

ment.  A  patient  may  lie  in  bed  leading  a  very  irregulai*  life,  and  doing 
just  about  what  she  chooses,  without  improving  in  the  least;  while,  if  her 
room  be  well  lighted,  her  diet  changed,  and  her  muscular  tone  kept  up, 
a  cure  may  be  often  wrought. 

I  am  not  inclined  to  place  any  faith  in  the  wonderful  accounts  of  "  me- 
talo-therapy  "  as  used  in  these  cases,  and  in  several  experiments  I  have 
made  I  have  come  to  the  conclusion  that  the  possible  increase  in  sensi- 
tiveness came  entirely  from  the  warmth  of  the  metal  applied  or  the  irrita- 
tion of  the  foreign  body.  If  the  skin  of  a  perfectly  healthy  person  be 
subjected  to  slight  rubbing  or  pressure,  and  a  point  be  applied,  he  will 
feel  the  application  much  more  acutely  than  in  other  parts  in  the  vicinity. 
For  acute  paroxysms  of  hysteria,  we  may  use  large  enemata  containing 
assafcBtida,  and  if  a  suppository  of  this  drug  in  combination  with  bella- 
donna is  inserted  every  night,  a  constant  influence  upon  the  patient  is  kept 
up  which  is  very  beneficial. 

HYSTERO-EPILEPSY. 

This  interesting  variety  of  nervous  trouble  has  received  a  great  deal 
of  attention  from  Charcot,^  Dunant,"  Dubois,  and  Bourneville,  as  well  as 
from  many  other  writers,  some  of  whom  did  not  recognize  its  distinct 
character  until  after  Charcot's  valuable  investigations  had  been  announced. 

Tissot*  says  that  "the  hysterical  attack  sometimes  resembles  epilepsy, 
so  much  so  as  to  have  received  the  name  epileptiform  hysteria,  but  the 
attack  nevertheless  does  not  possess  the  true  character  of  epilepsy." 

Others,  among  whom  are  Briquet,*  Landouzy,  and  Saunders,  have  also 
described  the  condition. 

Upon  the  authority  of  Charcot,'  the  combinations  of  epilepsy  and  hys- 
teria take  place  under  the  following  different  circumstances : — 

1.  a.  Epilepsy  being  the  primary  disease,  upon  which  hysteria  is  en- 
grafted, under  the  influence  of  emotional  causes  or  at  the  time  of  puberty. 

b.  After  marriage  (vide  Landouzy's  Case),  the  epilepsy  having  always 
existed.  After  connection,  the  hysterical  feature  of  the  attack  is  de- 
veloped. In  this  case  the  hysterical  character  of  the  epilepsy  subsided 
when  sexual  excitement  was  interrupted  by  pregnancy. 

2.  The  hysteria  being  primary,  the  epilepsy  is  added  thereto.  A  rare 
condition. 

3.  Convulsive  hysteria  coexisting  with  petit-mal. 

4.  An  epileptic  attack,  followed  by  hysterical  contractures,  anaesthe- 
sia, etc- 

I  have  observed  a  form  which  slightly  differs  from  any  of  the  above. 
The  patient,  an  epileptic,  was  seized  occasionally  with  hystero-epileptic 
attacks  during  the  menstrual  periods,  and  at  other  times  there  was  un- 


*  Lepons  sur  les  Maladies  du  Systenie  Nerveux,  part  i.,  Paris,  1872. 

*  De  I'Hyst^ro-^pilepsie.  ^  Maladies  des  Nerfs,  quoted  by  Charcot. 

*  Op.  cit.  5  Op.  cit.,  p.  324. 


HYSTERO-EPILEPSY. 


471 


complicated  epilepsy.     She  has  had  epilepsy  since  the  fifth  year,  when 
she  was  frightened  by  her  mother,  who  threatened  to  beat  her. 

Symptoms. — In  an  excellent  pictorial  work  published  by  Bourne- 
ville  and  Regnard,  the  admirable  clinical  assistants  of  Charcot,  a  num- 
ber of  plates  are  given,  some  of  which  I  have  reproduced  with  an  ab- 
stract of  the  description  by  the  authors. 

^"  The  prodromal  features  of  an  hystero-epileptic  attack  are  ovarian 
hypersesthesia,  the  globus  hystericus,  cardiac  palpitation,  constriction 
about  the  neck,  noises  in  the  ears,  violent  beating  of  the  temporal  arteries, 
obscure  vision,  etc.  The  immediate  attack  is  ushered  in  by  irregular 
respiration,  oppression  and  dyspnoea,  awkwardness  of  speech,  amounting 
to  embarrassment,  of  which  the  following  example,  which  occurred  in  one 
of  our  author's  cases,  may  be  presented.  After  the  prodromal  symptoms 
described  above,  the  patient,  with  hesitation  and  difficulty,  enunciated  the 
words :  "  J'ai  .  .  .  I'a  .  .  .  respiration  .  .  .  .  dif  .  . 
ficile     .     .     .     se     .     .     ne     .     .     .     .     serai     ....     pas 

.  ,  .  .  malade  .  .  .  afin  .  .  .  de  .  .  .  pas  .  .  . 
avoir  .  .  .  de  nitrite  d'amyle,"  in  the  way  they  are  written.  Some 
tumultuous  heaving  of  the  belly  then  follows,  the  eyelids  palpitate 
rapidly,  the  look  becomes  fixed,  the  pupils  dilated,  the  gaze  is  fixed  upon 
some  object  above,  then  she  loses  consciousness. 


(Fig.  61.) 


Tonic  Phase. — {Bourneville). 

The  actual  attack  is  characterized  by  an  initial  stage  (the  tonic  phase) 
of  tonic  convulsion.  The  entire  body  becomes  rigid,  the  arms  being 
usually  stretched  out,  and  the  hands  are  turned  in ;  there  is  a  movement 
of  circumduction  of  the  hands  and  forearms,  the  arms  being  drawn  across 
the  body,  and  the  back  of  the  hands  brought  together,  so  that  the 
knuckles  are  approximated  (see  Fig.  61).  The  inferior  extremities 'are 
stretched  out,  and  drawn  apart,  the  feet  being  in  the  position  of  equinus 
varus,  but  in  other  cases  the  feet  may  overlap  each  other,  the  toes  being 


1  See  author's  review  of  Bouraeville  and  Eegaard's  work,  Am,  Jour,  Med,  Science, 
July,  1879. 


472  CEREB  PvO-SPINAL    DISEASES. 

strongly  flexed.  The  face  is  contorted  and  suffused  with  blood,  and  the 
mouth  is  often  widely  opened,  or  in  some  cases  tightly  shut,  the  lips  being 
compressed  over  the  teeth.  Respiration  is  suspended,  the  pulse  is  with 
difficulty  perceived,  and  the  belly  is  immobile  and  contracted.  The  next 
phase  is  that  characterized  by  tetaniform  and  clonic  spasms,  the  head, 
which  was  drawn  downwards  and  to  one  side,  or  backwards,  returns  to  its 
normal  position,  the  facial  muscles  become  seized  with  clonic  spasms, 
and  the  eyelids  are  opened  and  shut  violently  but  somewhat  slowly.  A 
stertorous  phase  supervenes,  the  face  becomes  covered  with  large  drops  of 
sweat,  the  respiration  grows  noisy  and  violent,  and  there  is  frothing  at  the 
mouth.  A  period  of  repose  then  follows,  when  the  respiration  appears 
regular ;  there  are  movements  of  swallowing,  abdominal  gurglings  are 
heard,  and  undulations  of  the  abdominal  walls  become  apparent.  The 
clonic  phase,  \ih.\c\i  has  been  described  as  the  "  stage  of  contortion,"  is 
expressed  in  two  ways,  which  sometimes  succeed  each  other  in  the  same 
attack.  1.  In  clonic  movements  of  the  limbs  and  head,  which  is  rolled 
from  side  to  side.  The  face  is  red  and  engorged  with  blood,  the  neck  is 
stiff,  and  the  arms  are  stretched  out  and  contracted,  and  after  a  time  the 
patient  falls  violently  to  the  bed,  arising  and  falling  again  several  dif- 
ferent times.  At  the  same  time  the  rigidity  of  the  arms  disappears,  little 
by  little. 

2.  "  The  mouth  is  widely  opened,  the  tongue  is  protruded  ;  she  moves 
rapidly  to  the  side  of  the  bed  crying  oh  !  oh  !  (oite  !  one  !)  The  body 
becomes  curved  in  opisthotonos.  She  rests  on  the  back  of  the  head  and 
feet,  her  hair  is  dishevelled,  the  legs  are  convulsed  and  agitated  by  alter- 
nate movements  of  flexion  and  extension."    (See  Fig  62). 

A  new  period  of  repose  follows. 

By  far  the  most  intere-tiug  phase  of  the  disorder  now  makes  its  ap- 
pearance, viz.,  the  period  of  delirium.  In  Bourneville's  patients,  and 
in  fact  those  of  other  observers,  the  incidents  of  the  previous  life  figure 
conspicuously  in  the  delirium,  and  though  there  is  a  tendency  to  the  for- 
mation of  causeless  hallucination  of  the  horrible  kind,  in  which  reptiles, 
and  such  small  animals  as  rats  and  cats  figure  at  some  stage,  there  is  an 
old  impression  which  serves  as  a  field  for  the  development  of  a  delirium 
which  is  exhibited  by  gesticulations  and  facial  expressions  of  fear,  ecstasy, 
auger,  mockery,  erotism,  and  grief. 

The  patient  at  this  stage  a  sumes  an  attitude  and  expression  indicative 
of  her  emotional  condition.  She  may  remain  lying  upon  the  bed,  her 
body  inclined  to  one  side,  her  arms  resting  by  her  side,  her  face  upturned 
and  wearing  a  beseeching  look,  which  constitutes  the  "  Attitude  Passi- 
onelle"  of  Appeal.  At  another  time  she  clasps  her  hands,  sits  up,  turns 
her  face  upwards,  and  gives  expression  to  words  of  supplication,  such  as 
these ;  "  Tu  ne  veux  plus  ?  Encore  .  .  !  "  this  being  the  "  Sujjpli- 
cation  Amoreuse."  At  other  times  the  patient  lies  upon  her  back,  her 
arms  crossed  over  her  breast,  and  her  f  ice  wreathed  with  a  most  sensuous 
smile  (erotisme). 

The  variations  of  the  delirium  do  not  seem  to  b^  at  all  regular  in. 


HYSTEKO-EPILEPSY 


473 


their  mode  of  appearance  or  constancy,  but  there  is  a  general  similarity 
in  the  form  of  emotional  excitement  and  method  of  expression,  and  from 
an  inspection  of  either  of  the  cases,  it  ^vould  appear  that  for  several  days 
at  a  time  there  were  convulsive  attacks  followed  by  delirium,  in  which 
scorn,  mockery,  fear,  amorous  ecstasy,  subsequent  repose,  and  either  a  re- 
turn of  the  delirium,  or  fresh  convulsions,  occurred. 


Phase  of  Opisthotonos. — {^Bournevllle). 

There  may  be  fifteen  or  twenty  attacks  in  twenty-four  hours,  or  even 
many  more,  and  some  of  these  are  aborted  or  irregular,  at  such  times  the 
only  manifestations  being  those  of  a  purely  psychical  nature ;  the  syn- 
copal attacks  being  examples  of  this  kind.  In  rare  cases  the  clonic  phase 
(or  period  of  the  grand  movements)  is  followed  directly  by  the  extension 
of  the  arms  at  right  angles  from  the  body,  so  that  an  appearance  is  pre- 
sented which  has  been  called   Crucifiement,  or  the  position  of  crucifixion. 

This  is  usually  associated  with  the  portrayal  of  various  ecstatic  states, 
which  are  termed  by  Bourneville  beatitude,  etc.  The  first  of  these  is  most 
strikingly  portrayed  in  the  plate  which  is  here  reproduced.  (See  Fig.  6-3). 

An  occasional  feature  of  one  of  Bourneville's  cases  was  the  complication 
of  chorea,  which  was  manifested  at  diflerent  times  in  the  course  of  the  dis- 
ease. It  was  of  a  rhythmic  character,  and  involved  the  entire  body,  so 
that  the  trunk  was  drawn  backwards  and  forwards,  the  forearms  were 
flexed  and  extended,  the  hands  were  pronated  and  supinated  alternately, 
and  the  legs  and  thighs  flexed  and  extended,  the  right  eyelid  became 
closed,  and  the  muscles  of  the  right  side  of  the  neck  were  convulsed. 
This  occurred  in  paroxysms,  and  was  modified  under  ovarian 
pressure,  the  movements  becoming  less  violent,  and  finally  ceasing. 
When  the  compression  was  suspended,  the  movements  began  aueAV,  and  a 
violent  contraction  of  the  right  arm  and  leg,  which  had  lasted  during  the 
maintenance  of  pressure,  disappeared.  Ether  was  given,  and  again  the 
movements  were  suspended,  but  a  fresh  contraction  of  the  limbs  of  the 
right  side  took  place. 

In  one  or  other  of  these  cases  hemiansesthesia  and  ovarian  hypersesthesia 


474  CEREBRO-SPINAL    DISEASES. 

were  observed  from  time  to  time.  Contraction  of  various  organs  was 
quite  frequent,  and  was  sometimes  provoked  by  ovarian  pressure,  as  in 
the  case  just  detailed,  and  different  visual  disorders,  such  as  amaurosis 
and  disordered  color  sense,  were  discovered,  while  hallucinations  of 
vision  were  prominent  in  both  eases." 


Beatitude. — (Boumeville.) 

The  following  cases  were  my  own  : — 

Case  I. — A.  P.,  set.  18,  since  the  beginning  of  the  menstrual  epoch, 
has  suffered  from  her  present  form  of  hystero-epileptic  attacks,  which 
have  come  on  generally  just  after  the  cessation  of  the  catamenial  period. 
She  has  been  very  irregular,  and  has  suffered  from  amenorrhoea,  but  there 
is  no  uterine  disease  that  I  can  discover.  This  amenorrhoea  has  amounted 
to  an  entire  cessation  of  the  menstrual  flow  for  several  mouths  at  a  time, 
during  which  she  would  have  her  attacks.  Some  of  these  attacks  were 
like  that  I  shall  presently  describe,  and  lasted  for  several  days.  There 
was  no  succession  of  attacks,  but  usually  several  severe  but  distinct  epi- 
leptic seizures,  and  afterwards  an  hystero-epileptiform  paroxysm.  She 
had  been  in  the  Epileptic  Hospital  for  some  time,  and  had  given  a  great 
deal  of  trouble  by  her  irritability  and  mischief-making  propensities. 
Her  attacks  at  the  hospital  were  three  in  number  during  one  year,  each 
of  them  lasting  from  two  to  three  days  at  a  time,  during  which  there 
was  suppression  of  urine,  vomiting,  and  hemiauiesthesia,  which  in  one 
instance  was  on  the  right  and  twice  on  the  left  side. 

Her  most  pronounced  attack  occurred  while  she  was  staying  at  her 
mother's  house,  where  I  was  summoned  to  see  her.  This  was  on  the  14th 
of  March,  1877,  when  her  mother  came  to  my  office,  and  told  me  that 
her  daughter  had  been  ill  since  the  preceding  Thursday ;  that  she  had 


HYSTEEO-EPILEPSY. 


475 


gone  with  her  sister  to  see  a  friend ;  and  that  while  there  she  had  been 
seized  with  a  severe  fit,  and  could  not  go  home  until  the  next  day 
(March  9).  She  said  that  on  her  return  her  daughter  complained  of 
headache,  pain  in  the  back,  over  the  ovaries,  and  abdominal  discomfort, 
and  as  the  time  for  her  menses  had  come,  she  gave  her  a  pill  of  aloe  s 
and  myrrh  on  Saturday,  and  another  on  Sunday  night,  with  no  result, 
and  a  warm  hip-bath  on  Monday.  (She  had  not  menstruated  since 
December  1876.)  On  Monday  she  had  several  severe  epileptic  fits,  with 
frothing  at  the  mouth,  during  which  she  bit  her  tongue,  and  went  to  bed, 
where  she  remained  until  I  saw  her.  I  went  to  the  house,  and  found 
that  she  had  been  seemingly  unconscious  since  Monday  night,  that  she 
had  been  *'  frothing  at  the  mouth"  since  that  time,  and  that  on  Tuesday 
she  began  to  mutter  and  talk  to  herself ;  that  she  had  had  hallucinations 

Fig.  64. 


Hystero-Epilepsy. 

and  delusions,  some  of  them  of  a  painful  character,  believing  that  she 
had  been  followed  by  a  nurse  from  the  hospital,  whose  intention  was  to 
kill  her.  When  her  mother  entered  the  room,  she  berated  her  soundly, 
and  was  quite  abusive,  indulging  in  obscene  language. 

I  found  her  lying  upon  the  bed,  lightly  covered  by  a  sheet.  The  mus- 
cles of  her  back  were  rigidly  contracted,  so  that  her  position  was  one  of 
opisthotonos ;  her  head  was  turned  to  one  side,  and  her  tongue  was  pro- 
truded. Her  eyes  were  open,  and  the  pupils  widely  dilated,  and  insen- 
sible to  light.  Her  expression  was  blank,  and  she  was  apparently  un- 
mindful of  her  surroundings.  Her  arms  were  drawn  over  her  chest,  and_ 
her  forearms  slightly  flexed  and  crossing  each  other.  Her  thumbs  were 
bent  in,  and  covered  by  her  other  fingers,  which  were  rigidly  flexed. 
Her  pulse  was  124;  temperature,  101.2°;  respiration,  33.  She  was 
muttering  to  herself  a  disconnected  string  of  words  without  any  mean- 
ing, and  continued  them  during  my  visit.  She  had  not  eaten  for  twenty- 
four  hours,  and  I  ordered  milk  and  chloral  hydrate  in  twenty-grain 
doses,  to  be  forced  into  her  mouth  if  she  did  not  open  it  of  her  own  ac- 
cord. 

On  my  return  the  next  morning,  the  mother  told  me  that  she  had  had 
delusions  during  the  night,  and  had  cursed  those  of  her  family  who  ven- 
tured to  approach  her.  I  found  that  the  rigidity  of  the  previous  day  had 
become  less  marked,  but  that  her  right  hand  and  forearm  were  beneath 
the  lower  part  of  her  back.  The  right  corner  of  her  mouth  was  drawn 
downwards,  and  her  eyes  were   still  open,  and    the  cornese  ansesthetic. 


476  CEaEBRO-SPINAL    DISEASES. 

She  did  not  kaow  m3.  Terap3rature  100^  ;  pulse  lOS  ;  respiration  28. 
On  the  folltnviu^  m  )rning  Dr.  Charles  E  Lockw  )od  of  this  city  went 
with  013  to  see  her.  She  was  then  much  better,  and  was  less  rigid,  but 
the  right  haul  was  tightly  clenched,  and  no  persuasion  would  induce  her 
to  open  it.  Her  toes  were  also  flexed,  and  her  right  foot  presented  the 
appearance  called  by  Charcot,  '  le  pied  bot  hysterique."  Her  corne?e 
were  sensitive,  and  lier  pupils  less  dilated.  There  was  some  rolling  of 
the  eyeballs  from  side  to  side,  and  patient  occasionally  sighed.  Her 
pulse  was  now  only  96,  and  was  small  and  irritable;  the  temperature 
was  99^.  When  sharply  spoken  to,  she  said  •'  Doctor,"  and  relapsed  into 
a  state  of  stupidity,  turning  her  head  from  right  to  left,  and  staring  at 
the  ceiling.  She  occasionally  moved  her  tongue,  as  if  her  mouth  -was 
dry.  Dr.  Lockwood  suggested  the  experiment  of  frightening  her,  and  .so 
we  threatened  the  use  of  the  cautery,  the  mention  of  which  first  brought 
forth  remonstrance  and  afterwards  a  reply  to  our  questions. 

Her  mother  stated  that  she  had  not  passed  urine  for  several  days.  I 
did  not  find  a  distended  bladder,  but  when  the  catheter  was  introduced, 
it  brought  away  about  half  a  pint  of  light-colored  urine.  This  suppres- 
sion of  urine  continued  for  several  days.^  She  aro.se  from  her  bed  the 
day  after  this  last  visit,  and  her  menses  appeared.  Daring  the  next  three 
or  four  days  there  was  slight  hemiantesthesia  of  the  right  side. 

Case  II. —A  young  lady,  19  years  old,  had  been  my  patient  for  nearly 
a  year,  during  which  she  had  had  on  an  average  about  one  attack  of 
haut  mal  in  a  week.  Her  epilepsy  dated  from  the  ninth  year,  and  was 
not  dependent  upon  any  discoverable  cause.  At  all  times  she  is  irritable, 
pettish,  and  techy,  an  1  leads  a  very  irregular  life.  There  was  nothing 
remarkable  about  her  attacks  ;  they  were  not  very  violent,  nor  were  they 
connected  with  any  hysterical  manife.station.  There  was  rarely  any 
coma ;  but  the  attacks  were  more  severe  about  the  time  of  the  menstrual 
discharge,  which  was  never  abundant.  On  September  12,  1876,  I  was 
telegraphed  for  to  see  the  patient.  The  day  before  my  arrival,  without 
any  premonitions,  she  had  had  an  attack  very  much  like  all  the  others, 
but  instead  of  falling  asleep  sh-3  remained  convulsed,  and  apparently  un- 
conscious. She  vomited  two  or  three  times,  and  became  quite  cyanotic  ; 
so  the  local  physician  was  sent  for.  He  found  it  impossible  at  first  to 
open  her  mouth  to  remove  the  substance  which  had  collected  thorein  and 
distended  the  cheeks,  and  it  was  only  when  he  was  assisted  by  others  that 
he  could  do  so.  She  was  placed  in  bed,  and  remained  in  this  state,  the 
eyeballs  rolling  from  side  to  side,  the  body  drawn  slightly  to  the  right 
-side,  and  the  hands  clinched.  She  bacam  3  delirious  during  the  night, 
and  had  delusions  of  a  lively  kind,  like  those  of  a  patient  with  delirium 
tremens.  Oatbursts  of  hysterical  laughter  and  jactitations  of  the  limbs 
fjUowed  in  the  morning,  and  then  she  became  quiet,  but  the  muscles  were 
somewhat  rigid.  I  arrived  at  about  2  P.  M.,  and  found  her  lying  upon 
the  bed  with  open  eyes  and  meaningless  stare.  Her  right  hand  was 
rigidly  abducted,  and  the  bed-clothes  were  tightly  gra-^ped  in  her  hand. 
The  head  was  drawn  so  that  the  chin  was  approximated  somewhat  to  the 
chest.  The  teeth  were  set  together,  and  there  was  som3  grinding  of  the 
molars.  She  breathel  noisily,  there  bsing  an  accam illation  of  mucus  in 
the  throat.     Temperature  10[).2' ;  pulse  86.     Tne  pupils  were  dilated, 


^  It  is  probable  that  this  uriaarj  derangemeat  was  of  the  form  called  bj  Charcot 
oliguria.  • 


HYSTERO-EPILEPSY.  477 

and  seemingly  unaffected  by  light.  Pressure  upon  the  right  ovary 
caused  her  to  shrink  somewhat.  Her  abdomen  was  distended  by  flatus. 
During  the  night  she  became  somewhat  relaxed,  and  muttered  unintel- 
ligibly, but  in  a  petulant  tone.  She  fell  into  an  apparent  sleep  about  5 
A.  M.,  her  respiration  being  natural.  She  awoke  at  about  5  P.  M.  of 
the  same  day  (the  third),  and  though  somewhat  fatigued,  arose  and 
went  about.  She  was  not  hemiansesthetic,  but  ischuria  lasted  for  several 
days. 

An  inspection  of  the  cases  of  Charcot  and  others  will  enable  the  reader 
to  detect  certain  symptoms  which  are  alike  in  all  the  patients. 

Case  III. — Reported  by  Charcot.     Marc ,  23.     Hystero-epilepsy 

dated  from  the  16th  year;  attended  by  hemiansesthesia  and  hemijmresis 
of  left  side.  Daltonism  of  left  eye  ;  frequent  vomiting.  Attack  preced- 
ed by  an  aura  and  pain  in  left  ovary.  Attacks  included  three  stages  :  a. 
Tetaniform  contraction,  epileptiform  convulsions,  h.  Violent  movement 
of  trunk  and  lower  extremities  (period  of  contortion).  Silly  and  discon- 
nected talking.  Patient  appeared  to  be  semi-delirious,  c.  Laughing  fits; 
attacks  stopped  by  ovarian  compression. 

Case  IV. — Charcot.  Cot.,  21  years.  Hysteria  dated  from  the  15th 
year,  and  followed  cruel  treatment  at  the  hands  of  her  father,  when  she 
took  to  drink  and  became  a  prostitute.  Local  symptoms  are  :  right  hemi- 
ansesthesia, ovarian  pain,  permanent,  and  tremulation  of  the  right  lower 
extremity.  Convulsions  followed  ovarian  pain  ;  they  are  tonic,  and  she 
bit  her  tongue  and  frothed  at  the  mouth.  The  second  period  followed  at 
once,  and  was  marked.  The  attack  often  terminated  by  movements  of 
the  pelvis,  laryngeal  constriction,  crying  attack,  passage  of  large 
quantities  of  urine.  Ovarian  pressure  moderated  attack,  but  did  not  ar- 
rest it. 

Case  V. — Charcot.  Legr.  Genevieve,  28.  Hysteria  dated  from 
puberty.  Permanent  local  symptoms  ;  left  hemiansesthesia,  ovarian  pain, 
and  mental  peculiarities  (bizarre).  Aura  quite  marked,  and  so  are 
cardiac  palpitation  and  head  symptoms ;  attack  may  be  divided  into 
three  stages :  a.  Epileptiform  convulsion,  frothing  at  the  mouth,  and 
stertor.  b.  Movement  of  limbs  and  body,  c  Period  of  delirium,  dur- 
ing which  she  detailed  the  events  of  her  life.  Occasionally  last  stage 
would  be  characterized  by  hallucinations,  when  she  would  see  crows,  ser- 
pents, etc.  She  would  at  other  times  dance.  Ovarian  pressure  arrested 
attack. 

Case  VI. — Charcot.  Ler.,  48  years.  Attacks  date  from  early  life, 
when  she  was  frightened  by  a  dog,  and  by  the  sight  of  the  body  of  a  wo- 
man who  had  been  assassinated.  Local  symptoms :  hemiansesthesia  of 
ovary  ;  paresis  and  contractures  of  the  upper  and  lower  right  extremi- 
ties, and  occasionally  the  left.  Attacks  begin  by  ovarian  aura,  followed 
by  epileptiform  and  tetaniform  convulsions,  after  which  she  assumed  the 
most  trying  postures.  At  the  time  of  the  attack  she  falls  into  a  delirium, 
during  which  she  indulges  in  furious  invectives,  crying  to  imaginary 
persons  :  "  Villains,  robbers,  brigands  !  fire,  fire  !  Oh  the  dogs  !  oh,  I'm 
bitten  !"  these  being  suggested  by  memories  of  her  childish  fears.  When 
the  convulsive  part  of  the  attack  is  terminated,  there  follow :  1.  Hallu- 
cination of  sight,  the  patient  seeing  skeletons,  frightful  animals,  spectres, 
etc. ;  2.  A  paralysis  of  the  bladder  ;  3.  A  paralysis  of  the  pharynx ;  4. 
Finally,  a  more  or  less  permanent  contracture  of  the  tongue.     These  last 


478  CEEEBRO-SPINAL    DISEASES. 

symptoms  remain  for  several  days,  during  whicli  it  is  necessary  to  feed  the 
patient  with  a  stomach  pump,  and  then  draw  off  her  urine. 

Two  cases,  reported  some  years  ago,'  resemble  the  more  modern  hys- 
tero-epilepsy  so  closely  that  I  am  inclined  to  infer  that  they  were  attacks 
of  this  disease. 

Case  VII. — Arguinosa's  Case.  "Woman,  twenty  years.  Epileptiform 
convulsions  first  showed  themselves  during  infancy,  in  consequence  of 
head  injury.  They  reappeared  at  puberty.  While  residing  in  the  house 
of  Dr.  Arguinosa  she  complained  of  ovarian  pains.  The  precursory 
signs  of  an  epileptic  attack  soon  showed  themselves,  and,  on,  returning 
from  a  walk,  "  she  had  scarcely  time  to  throw  herself  on  a  bed  before  she 
lost  both  sensation  and  motion.  The  skin  was  hot,  respiration  loud,  pupil 
immovable,  eyelids  closed  convulsively,  limbs  flexible,  while  the  lips  were 
convulsively  moved,  or  else  a  sardonic  smile  sat  upon  them.  Bleeding  was 
about  to  be  practised,  when,  all  of  a  sudden,  after  some  horripilations, 
the  skin  bscame  cold  and  colorless,  the  pulse  and  respiration  were  sus- 
pended, and  the  patient  appeared  dead." 

Cold  affusion  to  the  head  seemed  to  produce  an  effect.  The  respiration 
then  became  agitated,  the  pulse  strong,  and  violent  convulsions,  with 
tetanic  rigidity  (pleurosthotonos)  set  in. 

She  became  angry  and  irritable,  screamed  out.  Noises  in  the  room, 
light,  and  the  steps  of  persons  around  her  were  sufficient  to  "  draw  her 
from  her  attacks  of  delirium."  She  had  a  presentiment  of  sudden 
death. 

"  Two  days  following  there  were  the  same  alternatives,  the  delirium 
occurring  less  frequently,  and  lasting  a  shorter  time ;  she  slept  but  little 
that  night  (the  4th)  ;  the  next  day  the  only  symptoms  noticed  were  aver- 
sion to  water,  light  and  air,  with  the  pain  of  stomach  previously  com- 
plained of.  On  the  sixth  day  she  asked  for  a  bath,  and  the  opium  which 
she  took  in  the  evening.  A  stool  brought  on  strong  convulsions  and 
noisy  delirium.  The  women  who  were  attending  to  her  believing  her  to 
be  possessed  by  the  devil,  sprinkled  her  with  holy  water,  which  increased 
her  furious  cries  and  bizarre  contortions.  The  following  night  was  dread- 
ful ;  the  mouth  full  of  foam,  the  eyes  injected,  and  the  delirium  almost 
continuous.  About  ten  in  the  morning  immoderate  laughter  succeeded 
the  previous  symptoms.     She  ultimately  died." 

Case  VIII. — Ward's  case.  Mary  P.,  aged  13.  Measles  at  age  of  7, 
and  has  ever  since  been  subject  to  cough  and  pain  in  the  side.  About 
one  year  ago  she  had  her  first  epileptic  fit,  during  which  she  attempted  to 
bite  and  scratch  the  bystanders.  She  was  not  insensible,  but  delirious. 
The  attacks  came  on  at  intervals  for  a  fortnight  afterwards,  and  they  be- 
came much  worse  at  the  end  of  this  time.  Her  arms  were  extended  and 
rigid,  and  the  fingers  clenched.  At  other  times  she  struggled  violently, 
and  the  abdomen  became  swelled.  She  never  became  unconscious.  Her 
disposition  was  changed,  for  she  grew  exceedingly  mischievous  between 
the  attacks,  developing  a  propensity  for  climbing  trees  and  playing  the 
hoyden.  Ovarian  pain  sometimes  The  attack  is  occasionally  finished 
by  a  fit  of  laughter. 

The  so-called  hysterogenic  zones  have  been  described  by  Richer^  Char- 

*  Forbes  Winslow's  Psychological  Journal,  vol.  ii. 
^Etudes  cliniques  sur  I'Hystero-epilepsie,  etc.,  Paris,  1881. 


CATALEPSY.  479 

cot  and  Mills  ^  tlie  latter  having  written  a  most  valuable  article  upon 
hystero-epilepsy  which  will  be  found  to  be  very  complete.  These  zones 
consist  of  limited  cutaneous  districts  which,  when  subjected  to  pressure, 
electric  excitation,  blistering  or  hot  or  cold  stimulation,  are  likely  to  give 
rise  to,  or  on  the  other  haad,  modify  or  stop  an  attack  of  hystero-epilepsy. 
These  are  bi-lateral,  and  are  situated  above  and  below  the  mammse,  over 
the  ovaries,  beneath  the  axillee,  over  the  ilia,  over  the  seventh  cervical 
spine  and  the  upper  dorsal  region.  The  form  of  excitation  varies  greatly, 
whether  the  patient's  surface  is  or  is  not  hypersesthetic  or  ansesthetic,  or 
in  proportion  to  the  severity  and  kind  of  impression.  Occasionally,  as  has 
been  ascertained,  the  excitation  of  these  regions  during  an  attack  may 
modify  the  character  of  the  delusions  during  the  stage  of  delirium.  The 
so-called  erotogenetic  zones  of  certain  French  writers  include  these  as  well 
as  other  spots — the  palmar  surface,  the  back  of  the  neck,  and  the  eyelids 
— which,  when  irritated  during  an  attack  are  followed  by  changes  in 
the  character  of  the  delirium,  the  patient  indulging  in  erotic  fancies. 

In  simple  hysteria,  pressure  or  irritation  of  these  spots  may  give  rise  to 
various  dysjesthesise. 

Charcot  holds  that  a  very  important  diagnostic  sign  is  the  reduced  tem- 
perature. In  epilepsy  the  temperature  may  even  rise  to  107.6"^  F.,  while 
that  of  the  hystero-epileptic  rarely  attains  a  height  of  100°  F.  In  the 
cases  I  have  alluded  to.  Case  I.  presented  all  the  prominent  symptoms 
by  him  enumerated,  and  still  the  temperature  was  quite  high. 

Treatment. — Nitrite  of  amyl  has  been  recommended  by  the  French 
authorities  for  the  suppression  of  the  attack.  I  would  recommend  nitro- 
glycerine for  the  same  purpose,  in  doses  of  tn.  v.  of  the  solution  spoken  of 
on  a  previous  page.  It  is  of  great  importance  that  the  pelvic  organs 
be  looked  after.  Dislocation  of  the  ovaries,  uterine  flexion,  or  troubles 
of  a  like  kind,  will  often  be  found  to  have  much  to  do  with  the  genesis 
of  hystero-epilepsy. 

CATALEPSY. 

Definition. — A  disease  closely  allied  to  hysteria,  of  extreme  rarity, 
and  characterized  by  a  condition  of  muscular  contraction  and  semi-rigid- 
ity, so  that  the  limbs  may  be  placed  in  constrained  and  awkward  posi- 
tions, and  remain  so  for  some  time.  It  is  attended  by  loss  of  consciousness, 
and  cutaneous  anaesthesia. 

Symptoms. — The  disease,  like  epilepsy,  is  characterized  by  attacks 
separated  by  intervals  of  greater  or  less  duration,  during  which  periods 
the  patient  is  usually  in  apparent  good  health. 

After  such  prodromata  as  malaise,  vertigo,  headache,  or  functional  tre- 
mor, the  individual  will  suddenly  be  seized.  He  may  be  talking  or  eat- 
ing, when  the  particular  act  is  arrested,  the  mouth  remaining  open,  or  the 
hand  half  raised.  The  muscles  become  rigid,  but  the  limb  may  be  moved 
by  the  physician  or  bystander,  and  if  placed  in  a  new  position,  no  matter 

1  American  Journal  of  Med.  Sciences,  Oct.,  1881,  p.  392. 


480  CEREBRO-SPINAL    DISEASES. 

\ 

how  awkward  it  will  remain  so  fixed  until  the  muscles  are  fatigued, 
when  it  drops.  Individuals  are  reported  to  have  remained  for  even 
an  hour  or  two  with  legs  or  arras  extended ;  and  in  one  case  I  saw  the  pa- 
tient remained  for  half  an  hour  with  the  right  arm  extended  in  a  straight 
line  from  his  shoulder,  and  the  other  extended  above  the  head.  The 
position  was  subsequently  changed.  The  peculiar  semi-rigidity  of  the 
muscles  has  gained  for  it  the  ndnne  fiexlbllltas  cerea,  on  account  of  a  "  wax- 
like "  mobility;  and  there  is  none  of  the  pronounced  stiffness,  or,  on  the 
other  hand,  limpness  of  the  limbs,  that  usually  attends  the  unconscious 
state.  The  surface  of  the  body  becomes  quite  cool ;  the  pupils  are  dilated  ; 
respiration  is  shallow  and  scarcely  perceptible;  and  it  is  sometimes  difficult 
to  find  the  pulse,  which  grows  thready,  but  nevertheless  preserves  its 
regularity. 

The  skin  is  anaesthetic  to  an  astonishing  degree.  Needles  may  be  thrust 
into  the  tissues  without  the  knowledge  of  the  individual,  and  pinching, 
slapping,  or  other  forms  of  cutaneous  stimulation,  produce  no  expression 
of  pain.  In  a  case  of  hystero-catalepsy,  seen  with  Dr.  D.  B.  St.  John 
Roosa,  I  repeatedly  thrust  pins  into  the  arms  and  legs  of  a  young  woman 
and  waV^hed  attentively  for  some  sign,  but  her  expression  was  immobile 
and  tranquil. 

It  is  stated  that  the  electro-muscular  contractility  is  not  affected,  but 
reflex  excitability  seems  to  be  diminished  or  lost  entirely,  so  that  some- 
times it  is  almost  impossible  to  determine  whether  the  patient  is  alive  or 
dead.  The  so-called  trance  states  are  examples  of  this  kind,  and  cata- 
lepsy has  undoubtedly  led  to  burial  alive  in  many  instances. 

The  ordinary  attacks  usually  subside  in  a  few  hours,  the  rigidity  grow- 
ing less  marked,  and  consciousness  gradually  returning.  The  attacks,  as 
a  rule,  follow  each  other  in  a  series,  and  then  comes  an  interval  of  normal 
health.  In  this  mode  of  appearance  and  behaviour,  the  disease  has  been 
likened  by  Eulenburg  to  neuralgia.  "  Strictly  speaking,  it  is  rather  a 
cycle  of  attacks  quickly  following  one  another ; "  and  there  are  remis- 
sions characterized  by  a  temporary  return  of  consciousness,  and  then  a  fresh 
relapse,  which  evidently  follows  some  internal  irritation.  In  rare  cases 
there  is  a  sudden  return  of  consciousness  and  an  ability  to  perform  volun- 
tary acts.    The  urine  and  feces  are  rarely  passed  in  an  involuntary  manner. 

Unless  the  disease  be  due  to  malaria,  it  becomes  chronic,  and  continues 
for  years.  If  it  is  due  to  malarial  poisoning,  it  usually  assumes  a  regular 
periodic  character,  and  is  amenable  to  treatment. 

Causes. — Like  many  other  neuroses,  such  as  hysteria,  epilepsy,  and 
those  of  this  class,  mental  excitement  plays  no  mean  part  in  the  etiology 
of  catalepsy.  Fright,  and  other  forms  of  emotional  excitement  enter  into 
its  causation.  Injury  and  malaria  may  also  be  mentioned,  while  mastur- 
bation, venery,  and  intestinal  worms  are  spoken  of  by  writers  generally. 
Jaccoud  considers  it  to  be  a  result  or  accompaniment  of  certain  forms  of 
melancholia  (Melancholia  attonita),  and  ecstacy. 

It  appears  as  if  it  were  more  common  in  early  life,  and  children  are 
therefore  nearly  always  the  victims.     Antemic  girls,  or  boys  especially 


CATALEPSY.  481 

"who  study  too  constantly,  are  affected  more  often  than  those  of  adult  life. 
Nearly  all  writers  agree  that  the  female  is  more  subject  to  the  disease  than 
the  male,  and  probably  the  delicate  organization  of  the  sexual  apparatus 
has  much  to  do  with  this.  Hereditary  influences  seem  to  play  a  part  in 
the  etiology  only  so  far  as  the  general  neurotic  tendency  is  concerned. 
Families  in  which  there  is  epilepsy,  neuralgia,  or  insanity  sometimes 
include  cataleptic  members.  I  have  never  heard,  and  I  can  find  no  re- 
cord, of  transmitted  catalepsy. 

Morbid  Anatomy  and  Pathology. — Besides  the  autopsies  made 
by  Calmeil  and  other  older  writers,  which,  by  the  way,  throw  very 
little  light  upon  the  question  of  pathology,  Schwartz  made  one  autopsy, 
and  Lasegue  two,  but  nothing  was  found  by  the  latter  observer. 

Schwartz^  mentions  the  case  of  a  boy  "who,  after  an  injury,  had  at  first 
attacks  resembling  chorea,  later  cataleptico-tetanic  attacks,  and  after  two 
years  died  from  anaemia  and  marasmus.  There  was  found  in  this  case, 
besides  a  serous  effusion  in  the  arachnoid,  a  softening  of  the  corpus 
striatum  and  optic  thalamus,  on  the  left  side;  along  the  posterior 
surface  of  the  spinal  cord,  from  the  cervical  to  the  lumbar  enlargement, 
was  a  brownish-red,  jelly-like  mass,  arranged  in  groups,  covering  the  dura 
mater.  The  spinal  cord  seemed  healthy.  (There  was  no  microscopic 
examination.)" 

Catalepsy,  which  is  associated  with  many  other  interesting  perversions 
of  consciousness  such  as  somnambulism,  stigmatization,  etc.,  has  received 
a  great  deal  of  attention,  not  only  from  the  laity,  but  from  scientific  men 
of  all  ages.  It  is  not  my  purpose  to  enter  extensively  into  the  consideration 
of  these  various  curious  states.  The  lighter  forms,  such  as  the  "catalepsie 
passagere"  of  Lasegue,^  have  been  induced,  by  mesmerists  and  others,  by 
passing  the  hand  over  the  face  or  body,  or  by  closing  the  eyelids.  The 
same  condition  may  be  induced  by  looking  fixedly  at  some  bright  object 
held  close  to  the  face. 

A  remarkable  experiment  of  a  popular  nature,  which  I  have  repeatedly 
performed  myself,  is  a  curious  instance  of  the  susceptibility  of  certain 
animals  to  influences  of  this  kind.  If  a  lobster  be  placed  head  downwards, 
and  gentle  scratching  of  the  back  is  made,  it  will  become  perfectly  quiet, 
no  matter  how  pugnacious  it  has  been  before,  and  will  remain  in  this 
position  for  some  time. 

The  general  opinion  in  regard  to  the  pathology  of  the  affection  is  that 
the  peculiar  muscular  condition  is  due  to  an  increased  muscular  tone, 
which  probably  depends  upon  impaired  voluntary  control,  so  that  the 
muscles  respond  to  trivial  irritation  reflected  upon  the  spinal  ganglion 
cells. 

Volition  is  checked  just  as  it  is  in  hysteria;  and  when  we  consider 
the  theory  of  "  expectant  attention,"  advanced  by  Carpenter,  the  genesis 
of  some  forms  of  catalepsy  is  easily  explained.     These  are  the  varieties  in 

^  Quoted  by  Eulenburg  in  Ziemssen's  Encyclopaedia,  vol.  xiv.,  translation. 
2  Archives  Gen.  de  Med.,  1865. 
31 


482  CEREBRO-SPIKAL    DISEASES. 

■which  the  individual  becomes  cataleptic  when  influenced  by  another.  The 
time  has  not  yet  come  for  the  admission  of  mooted  subjects  like  trance 
and  double  consciousness  into  text-books  for  students  ;  I  therefore  await 
the  further  development  of  the  subject,  which  at  present  is  in  a  chaotic 
state  of  confusion. 

Diagnosis. — The  waxy  flexibility,  which  is  pathognomonic,  is  not  a 
feature  of  any  other  disease,  and  this,  taken  in  connection  with  the  loss  of 
consciousness  and  ansesthesia,  makes  the  diagnosis  a  matter  of  certainty. 
The  only  point  which  should  interest  us  is  the  possibility  of  simulation. 
Numerous  instances  of  so-called  stigmatization  come  under  this  head. 
There  is  abundant  opportunity  for  detection,  however ;  and  electricity, 
mental  influence,  and  strong  cutaneous  revulsives  are  recommended  should 
•we  suspect  malingering. 

Prognosis. — When  the  cause  is  emotional,  or  when  there  is  a  malarial 
influence,  the  individual's  chances  are  remarkably  good.  It  is  only  when 
the  disease  appears  in  a  subject  of  very  marked  nervous  temperament 
that  there  is  any  reason  to  give  a  bad  prognosis,  and  such  cases  are  chro- 
nic.    A  fatal  termination  is  a  very  remote  possibility. 

Treatment. — Electricity  in  its  induced  form  seems  to  be  indicated 
for  the  abortion  or  relief  of  the  paroxysm,  and  amyl  nitrite  may  be  re- 
commended for  the  same  purpose.  Should  there  be  malarial  influences, 
quinine,  arsenic,  or  iron  are  of  course  in  order.  Curare,  bleeding,  and 
many  other  forms  of  treatment  have  been  useless.  In  the  transitory 
affection  (catalepsie  passagere)  cold  water  douches,  or  diff'usible  stimulants, 
are  resorted  to.  The  cataleptic  and  hystero-epileptic  conditions  are  often 
attended  by  very  great  flatus,  and  when  this  is  removed  the  patient  quite 
often  immediately  recovers.  An  ounce  or  so  of  the  tincture  of  assafoetida 
may  be  put  in  a  quart  of  hot  water  and  the  woman  is  to  be  given 
an  enema  therewith,  a  folded  napkin  being  held  by  the  nurse  over  the 
anus.  In  other  cases  the  rectal  tube,  such  as  is  used  by  Emmet,  may  be 
tried.  I  would  strongly  discountenance  a  modern  operation  for  the  removal 
of  the  ovaries.  I  have  seen  one  case  where  this  was  tried.  The  result 
was  death  within  three  or  four  days.  There  are  so  many  causes  that  may 
enter  into  the  production  of  catalepsy  that  it  seems  an  unwarrantable 
assumption  to  fix  upon  the  ovaries  as  the  offending  organs.^ 

1  The  Principles  and  Practice  of  Gynsecology,  1st  Ed.,  p.  201. 


CHOEEA.  483 


CHAPTER   XV. 

CEREBRO-SPINAL  DISEASES  (Contintjed.) 
CHOREA. 

Synonyms. — St.  Vitus's  dance ;  St.  Jolin's  dance  ;  ^  Paralysis  vacil- 
lans ;  Tarantismus  ;  Choree ;  Veitz  tanz,  etc. 

Definition. — Chorea  is  a  disease  characterized  by  involuntary  and 
disorderly  movements  of  the  muscles,  is  unattended  by  loss  of  conscious- 
ness and  cutaneous  sensibility,  and  may  be  connected  with  paresis  of  cer- 
tain groups  of  muscles,  or  those  of  one  side  of  the  body. 

As  early  as  the  fifteenth  century,  a  species  of  religious  delusion  appeared 
in  Southern  and  Middle  Europe,  in  an  epidemic  form,  and  was  connected 
with  certain  saltatory  and  muscular  phenomena,  which  gained  for  it  the 
name  of  St.  Vitus's  dance. 

This  is  described  by  various  writers  as  a  condition  of  religious  excite- 
ment characterized  by  gesticulation,  contortions  of  the  body,  and  leaping, 
while  the  patient  generally  screamed  or  howled  like  an  animal.  This 
peculiar  state  was  supposed  by  the  older  writers  to  be  demoniac  possession, 
and  many  victims  were  made  to  undergo  the  ordeal,  or  were  put  to  death 
by  the  sword,  or  burnt  at  the  stake.  Under  the  influence  of  their  condi- 
tion they  sought  the  shrine  of  St.  Vitus,  which  was  situated  in  a  small 
chapel  near  Zabern.  Here  they  were  cured  by  the  priests,  who  sang 
masses  and  removed  the  disorder.^ 

Various  epidemics  appeared  subsequently,  but  the  disease  gradually 
became  divested  of  its  noisy  character.  In  Italy  a  dancing  disease,  sup- 
posed to  be  due  to  the  bite  of  the  spider,  and  which  received  the  name  of 
tarantism,  made  its  appearance  in  the  early  part  of  the  sixteenth  century, 
while  at  the  same  time,  a  peculiar  outbreak  occurred  at  Amsterdam, 
where  seventy  children  of  the  Orphan  Asylum  became  possessed.  They 
climbed  the  walls,  swallowed  needles,  hairs,  pieces  of  glass,  and  other  in- 
digestible substances,  and  "  distorted  their  features  and  limbs  in  a  fearful 
manner."^ 

At  other  places  the  same  thing  occurred,  and  until  the  end  of  the  seven- 
teenth century,  when  there  was  some  decrease  in  superstition,  instances  of 
this  kind  of  chronic  disorder  were  common. 

^  For  a  most  entertaining  description  of  this  affection  read  Hecker's  Epidemics  of 
the  Middle  Ages,  third  edition,  Sydenham  Society's  Transactions. 
^Eeynolds's  System  of  Medicine,  vol.  ii. 
^  Scheie  de  Vere's  "  Modern  Magic,"  p.  357. 


484  CEREBRO-SPINAL    DISEASES. 

Symptoms. — The  beginning  of  a  simple  case  of  chorea  may  be  the 
following:  The  patient,  a  boy  of  ten  years,  who  attends  school,  becomes 
irritable,  loses  appetite,  and  does  not  care  to  go  out  and  play  with  his 
fellows.  He  becomes  pale  and  thin,  and  sits  by  himself  In  a  little  while 
some  movement  of  the  hand  or  fingers,  some  twitching  of  the  face,  or 
dragging  of  one  foot  when  he  walks,  attracts  the  attention  of  parent  or 
teacher.  He  may  be  punished,  with  the  idea  that  such  movements  are 
the  result  of  bad  habits  or  viciousuess,  but  it  does  no  good,  and  probably 
increases  the  trouble.  These  jactitations  cease  at  night,  when  he  rests  un- 
easily, and  is  disturbed  by  bad  dreams.  This  is  the  condition  in  which 
we  find  the  patient.  What  is  the  course  of  the  disease?  If  he  is  neglected, 
it  will  not  be  long  before  the  convulsive  movements  become  general.  The 
feet  may  drag  along  as  if  paralyzed,  and  such  is  the  case.  He  will  be 
unable  to  button  his  clothing,  or  attend  to  his  little  wants,  and  may  need 
the  careful  and  constant  attention  of  his  friends.  The  vocal  cords  may 
be  affected,  and  there  is  as  a  result  a  certain  aphonia,  so  that  phonationis 
husky  and  subdued.  Inco-ordination  of  the  lips  and  tongue  gives  rise  to 
difficulties  in  articulation,  which  are  quite  distressing,  the  words  being 
"  snapped  "  and  cut  short.  Mitchell  uses  the  term  "  habit  chorea  "  for  a 
light  form  of  the  trouble,  which  consists  perhaps  only  of  some  repeated 
grimace,  or  shrugging  of  the  shoulders. 

The  symptoms  are  worthy  of  separate  consideration,  and  we  will  pro- 
ceed to  discuss  them  in  their  order  of  importance. 

1.  Motility} — The  spasms,  as  I  have  said,  are  clonic,  and  are  more 
often  unilateral  than  bilateral.  The  right  hand  is  usually  affected  first, 
then  the  leg  of  the  same  side  may  follow,  and  finally  the  other  side  may 
be  implicated,  so  that  the  movements  are  general.  The  arm  is  usually 
involved  before  the  face,  though  in  several  of  my  personal  cases  the  first 
symptom  noticed  was  a  slight  twitching  about  the  mouth,  and  an  awkward 

^  In  an  excellent  report  of  80  cases  of  Chorea,*  made  by  Dr.  G.  S.  Gerhard,  of  the 
Philadelphia  Orthopsedic  Hospital  and  Infirmary  for  Nervous  Diseases,  the  following 
points  were  observed  : — 

Movement. — In  27  cases,  general. 

II     "  ''         but  marked  on  right  side. 

10     "  "  "         "  left        " 

32     "     unilateral,  20  on  right,  12  on  left  side. 

In  a  certain  number  of  these  cases  the  movements  shifted  to  the  other  side. 
Paralysis. — Partial  paralysis  noted  in  17  cases.      Loss  of  power  in   10  instances 
confined  to  right  side,  in  7  to  left. 

Age. — Under  10  years,  28  cases,    9  m.,  19  fern. 

From  10  to  20       "     52      "      18    "    3-4    " 

Total,  80      "      27    "    53    " 

Cure  in  56  cases,  improvement  or  ''  result  unknown  "  in  24  cases. 


*  Amer.  Journ.  of  the  Medical  Sciences. 


CHOREA.  485 

tendency  manifested  by  the  child  to  open  the  mouth  and  draw  its  breath 
while  speaking.  In  another,  the  little  boy  first  attracted  the  notice  of  his 
mother  by  movements  of  the  alse  of  the  nose. 

I  do  not  think  that  the  movements  in  chorea  are  always  increased  by 
the  efibrt  of  the  will  to  stop  them,  as  is  the  case  in  sclei'osis,  in  which  disease 
the  tremors  are  exaggerated  by  any  voluntary  attempt  of  the  individual 
at  control ;  and  I  have  often  been  led  to  suppose  that  chorea  might  be 
divided  into  two  varieties,  viz.,  one  in  which  the  movements  are  increased 
with  the  exercise  of  the  will,  the  other  when  they  are  most  violent  in  a  state 
of  rest.  The  movements  of  the  hands  are  characteristic,  I  think.  There 
is  a  prehensile  movement  of  the  fingers  and  a  rubbing  of  the  ball  of  the 
thumb  and  ends  of  the  fingers.  There  is  swinging  of  the  arm,  and  a 
shrugging  of  the  shoulder,  as  if  the  patient  had  on  large  or  uncomfortable 
underclothing. 

There  is  a  trivial  point  which  may  perhaps  be  of  interest,  and  I  only 
mention  it  because  it  is  unique.  I  allude  to  the  habit  which  these  little 
patients  have  of  rubbing  the  seam  of  the  trowsers  leg  by  the  hand  which 
is  afiected,  for  these  movements  often  go  on  most  actively  when  the  arm 
hangs  by  the  side,  and  when  the  attention  is  not  directed  to  it.  In  other 
diseases  just  such  "  little  straws  "  will  once  in  a  while  give  a  serviceable 
hint;  for  instance,  in  commencing  paresis  of  any  kind  of  the  lower  limbs. 
If  we  examine  the  tip  of  the  shoe,  we  will  find  the  sole  to  be  worn  down 
on  one  side  of  the  body.  In  locomotor  ataxia  we  will  find  a  reduction  of 
the  heel.  "When  these  little  patients  are  worried  or  embarrassed,  the 
movements  are  greatly  increased,  and  this  is  one  of  the  strong  features  of 
diseases  of  this  kind.  I  have  at  present  a  patient  at  the  Hospital  who  is 
almost  quiet  when  in  the  presence  of  people  he  has  been  associated  with 
for  some  time,  but  every  new  face  seems  to  excite  him  to  such  a  degree  as 
immediately  to  give  rise  to  the  most  violent  movements. 

The  loss  of  power,  which  is  very  often  a  phenomenon  of  chorea,  is 
nearly  always  one-sided,  and  when  it  exists  to  a  marked  degree,  may 
greatly  affect  the  patient's  walk,  so  that  he  drags  his  foot  in  a  helpless 
manner.  Handfield  Jones  thinks  that  the  want  of  power  is  a  constant 
feature  of  the  disease.  Such  paresis  is  extremely  variable,  however,  in  its 
extent.  Muscular  exertion  is  distressing,  and  he  may  not  have  the  power 
to  perform  some  of  the  least  fatiguing  actions  of  daily  life  without  great 
prostration. 

The  muscles  that  are  most  paralyzed  are  always  those  which  have  been 
the  seat  of  the  most  violent  spasm. 

Sensation. — There  may  be  pain  in  the  wrists  if  the  spasms  are  severe, 
or  the  skin  may  be  ansesthetic ;  such  loss  of  sensation  being  confined  to 
the  whole  paralyzed  side,  or  to  a  single  limb. 

Mental  Condition. — Irritability  of  temper  and  emotional  excitement 
are  present  from  the  beginning,  and  the  child  is  restless,  sleeps  lightly 
and  is  tortured  by  bad  dreams.  Study  or  mental  application  is  an  impos- 
sibility, and  spells  of  crying  are  quite  familiar  evidence  of  the  disease, 


486  CEREBRO-SPINAL    DISEASES. 

especially  in  the  earlier  stages.  Chorea  may  exist  iu  a  very  severe  form 
■when  there  is  a  grave  exciting  cause ;  and  the  convulsive  movements  may 
be  so  violent  as  to  render  it  necessary  to  bind  or  hold  the  patient  in  bed. 
At  the  request  of  Dx\  J.  P.  P.  White,  of  IS  ew  York,  I  saw  with  him  a  case 
of  this  kind. 

The  little  girl,  who  was  about  ten  years  of  age,  had  arrived  in  New 
York  after  a  sea-voyage,  during  which  the  symptoms  began.  We  found 
her  agitated  by  violent  spasms  of  all  four  extremities,  which  had  lasted 
for  several  days,  and  it  required  constant  watching  to  keep  her  from 
throwing  herself  out  of  bed.  They  ceased  partially  during  sleep,  but 
this  needed  repose  was  denied  her  to  a  great  extent.  Her  skin  was  hot, 
and  her  pulse  bounding  and  full.  She  was  perfectly  couscivus,  but  com- 
plained of  pain  in  the  wrists.  I  inferred,  from  the  general  character  of 
the  convulsions,  their  constancy  and  violence,  and  from  other  symptoms, 
that  there  was  some  form  of  eccentric  irritation ;  and  an  anthelmintic  ad- 
ministered by  Dr.  White  brought  away  a  tapeworm  several  yards  long. 
The  movements  disappeared  in  a  very  short  time. 

The  urine  had  been  found  by  Walshe  and  Bence  Jones  to  be  of  much 
higher  specific  gravity  than  in  health,  and  to  contain  an  excess  of  urea. 
It  may  vary  from  1030  to  1040,  and  is  loaded  with  the  oxalates  and 
lithates. 

Another  form  has  been  described  which  is  characterized  by  paroxysms, 
during  which  the  patient  may  perform  the  strangest  antics.  Her  condi- 
tion before  and  after  the  attack  is  one  of  quietude,  but  without  warning 
she  becomes  agitated  by  spasms,  rolls  on  the  floor,  jumps  in  the  air,  or 
rushes  about  the  room.  Wood  reports  a  case  of  this  kind,  in  which  the 
patient,  a  young  married  woman  who  had  been  slightly  ill  for  some  time, 
developed  this  paroxysmal  variety.  "  The  paroxysms  themselves  were  not 
always  of  the  same  kind.  At  one  time  she  would  be  violently  and 
rapidly,  hurled  from  side  to  side  in  the  chair  in  which  she  might  happen 
to  be  sitting,  or  else,  suddenly  gaining  her  feet,  she  would  go  on  jump- 
ing or  stamping  for  a  while ;  or,  she  would  rush  around  and  around 
the  room,  and  would  rap  with  her  hands  each  article  of  furniture  which 
lay  in  her  course ;  or  she  would  spring  aloft  many  times  in  succession 
and  strike  the  ceiling  with  the  palm  of  her  hand,  so  that  it  became  ne- 
cessary to  remove  some  nails  and  hooks  which  had  done  her  an  injury  ; 
or  she  would  dance  upon  one  leg  with  the  foot  of  the  other  leg  in  her 
hand." 

A  professional  friend  has  recently  informed  me  of  a  case  of  this  kind 
which  came  to  his  knowledge,  in  which  the  woman  was  affected  very  much 
in  the  same  way  as  the  patient  of  Mr.  Wood,  and  that  on  one  occasion  she 
created  great  commotion  by  attempting  to  climb  one  of  the  stanchions  in 
the  cabin  of  a  steamboat. 

These  cases  are  so  rare,  however,  that  they  only  deserve  to  be  men- 
tioned en  2iassant  as  examples  of  the  irregularity  of  the  disease,  and  are 
somewhat  like  the  original  dances  of  St.  Vitus  and  St.  John. 


CHOREA.  487 

The  following  case  illustrates  a  very  curious  phenomenon  of  motility 
which  I  lately  noticed  : 

The  patient,  a  boy  of  ten  years,  was  brought  to  me  by  his  father  for 
treatment,  after  having  been  seen  by  many  practitioners,  who  did  not 
agree  in  regard  to  his  condition.  I  saw  that  his  movements  were  choreic. 
Questioning  revealed  the  fact  that  he  had  never  been  a  strong  child,  but 
had  always  been  disposed  to  nervous  troubles ;  even  the  exanthematous 
fevers,  which,  like  other  children,  he  had  had,  were  generally  connected 
with  stupor,  and  other  evidence  of  susceptibility  of  the  nervous  fsubstance 
to  blood-poison.  He  never  had  any  rheumatic  or  cardiac  affections,  and 
I  could  hear  nothing  to  indicate  valvular  trouble.  The  heart-sounds  were 
sharp  and  quick,  however.  Four  years  ago  he  began  to  decline,  became 
weak  and  anaemic,  was  irritable,  moody,  and  bad-tempered.  His  appetite 
was  capricious,  and  he  preferred  sweets  to  other  food.  In  the  summer  of 
1872  the  movements  in  the  hands  and  arms  began,  and  soon  became  gen- 
eral. His  rest  was  uncomfortable,  and  he  started  up  in  his  sleep  and 
cried  out.  When  I  saw  him  four  months  ago  he  was  a  pitiable  object. 
His  movements  were  general.  He  was  unable  to  hold  anything,  and  was 
powerless  to  perform  any  voluntary  actions  except  those  of  a  gross  kind. 
He  could  not  unbutton  his  clothing  or  put  on  his  cap  ;  his  mother  even 
had  difficulty  in  making  him  walk. 

Variety  of  Movement. — Head  was  violently  agitated,  there  being  con- 
tractions of  the  sterno-cleido-mastoideus.  He  "  sucked  in  his  cheeks,"  and 
pursed  up  his  mouth,  smacking  the  lips.  Other  facial  contortions  were 
violent.  He  winced  spasmodically,  and  there  was  constant  motion  of  the 
eyeballs. 

The  arms  were  in  constant  motion,  but  the  right  was  not  affected  so 
much  as  the  left.  The  right  arm  and  hand  were  slightly  paretic,  and  he 
was  able  to  force  the  column  of  fluid  in  the  fluid  dynamometer  up  to  16°, 
which  is  equal  to  15  lbs.  pressure  to  the  square  inch.  The  left  forced  it 
up  to  18°. 

The  legs.  The  right  leg  was  also  slightly  paretic.  The  toe  of  the  shoe 
was  worn  down  to  some  degree,  althouglx  the  walk  was  not  noticeably 
affected. 

There  was  an  uneasy  rolling  of  the  pelvis  when  he  sat  down,  and  the 
legs  were  not  entirely  under  his  control.  There  was  pain  in  the  wrists 
and  ankles.  Under  proper  management  of  his  diet  he  gradually  improved, 
and  at  the  last  visit  was  nearly  well.  I  noticed  then  for  the  first  time  the 
following  peculiar  state  of  affairs.  When  sitting  in  front  of  me,  I  told  him 
to  raise  his  hands,  one  after  the  other.  The  right  hand  he  raised  promptly, 
but  the  left  he  could  not,  unless  he  took  hold  of  the  wrist  with  the  other 
hand,  and  lifted  it.  This  condition  struck  me  as  remarkable,  especially 
as  he  had  to  repeat  the  process  of  aiding  with  the  right  hand. 

The  left  hand  and  forearm  might  be  paretic.  There  was  no  loss  of 
electro-muscular  contractility,  however,  but,  if  anything,  it  was  increased. 
The  muscular  power,  tested  by  the  dynamometer,  was  found  to  be  even 
better  than  in  the  other  hand.  There  was  no  atrophy.  With  these  facts 
in  view,  it  seemed  improbable  that  this  should  be  the  cause. 

It  was  found  that  when  the  other  hand  ivcis  held  down,  the  boy  was 
able  to  lift  his  left  hand  untssiited,  and  even  to  raise  a  dumb-bell  loeighing 
10  lbs.,  but  as  soon  as  the  other  hand  luas  released  he  ivas  unable  to  re- 
peat  it. 


488  CEBEBRO-SPINAL    DISEASES. 

To  determine  whether  this  was  the  result  of  any  bad  habit,  I  ascertained 
from  the  father  that  his  son  had  never  used  one  hand  to  lift  the  other  till 
a  few  weeks  ago. 

In  adult  life  forms  of  chorea  are  met  with  which  in  nearly  every  respect 
resemble  those  of  infancy.  Sometimes  pregnancy  is  the  cause,  and  in 
other  cases  prolonged  emotional  excitement,  and  more  especially  grief, 
are  in  some  way  connected  with  the  development  of  the  disease. 

My  case-book  contains  the  records  of  several  of  these  examples,  and 
their  form  is  usually  of  that  kind  which  is  known  as  hemichorea,  and  very 
often  seems  to  be  dependent  upon  some  true  organic  lesion.  In  this  form 
the  exercise  of  the  will  to  stop  the  movements  is  generally  provocative  of 
a  decided  increase  in  their  violence.  The  patient  is  unable  to  carry 
food  to  his  mouth,  to  manage  his  clothing,  or  to  perform  any  little  acts 
of  necessity.  He  fears  to  make  any  attempts  in  the  presence  of  other 
people,  and  this  is  especially  the  case  before  strangers.  I  have  already 
alluded  to  one  instance  of  this  kind.  In  another  patient  the  mere  sugges- 
tion of  meeting  a  new  physician  was  sufficient  to  aggravate  her  convulsive 
movements. 

The  chorea  occurring  during  pregnancy  generally  disappears  before 
parturition,  and  Jaccoud  considers  that  it  may  lead  to  miscarriage,  and 
he  has  found  the  mortality  greater  than  in  any  other  form.  I  am  not 
disposed  to  agree  with  him  as  to  the  serious  character  of  the  disorder. 

An  instructive  case  of  this  disease  is  subjoined  : — 

Mary  K.,  set.  24,  entered  the  Epileptic  and  Paralytic  Hospital  July 
10th,  1877.  She  is  of  nervous  temperament,  and  gives  a  family  history 
of  nervous  disease.  Her  sister  has  epilepsy,  and  a  brother  has  infantile 
paralysis.  Up  to  the  fifth  day  of  June,  1877,  she  was  perfectly  well. 
While  in  bed  she  was  awakened  by  a  storm  at  about  3  A.  M-,  and  was 
greatly  frightened  by  the  loud  claps  of  thunder  and  the  vivid  lightning. 
She  arose  and  fell  to  the  floor,  where  she  lay  for  some  time,  crying,  but 
found  no  difficulty  in  arising,  there  being  no  paralysis.  The  next  day 
she  felt  "a  cramp  "  in  the  left  side,  and  the  leg  and  arm  were  spasmodi- 
cally contracted,  and  afterwards  began  to  twitch.  There  is  no  profound 
loss  of  power  whatever,  but  some  slight  paresis  of  the  left  side,  and  a  de- 
cided hyperiesthesia  of  this  part  of  the  body.  The  left  upper  and  lower 
extremities  were  convulsed  by  choreiform  movements,  the  hand  being 
more  agitated  than  the  leg.  The  strength  of  grip  is  decidedly  weakened, 
and  she  is  only  able  to  force  the  fluid  index  in  the  dynamometer  up  to  8°, 
while  with  the  other  hand  she  raised  it  to  14°.  There  is  some  dragging 
of  the  foot  when  she  walks.  She  does  not  sleep,  but  requires  chloral  and 
other  hypnotics.  She  is  in  her  seventh  month  of  pregnancy,  and  it  was 
decided  not  best  to  try  any  very  active  treatment.  Arsenic  was  given, 
however,  in  the  form  of  five-minim  doses  of  Fowler's  solution,  and  she 
became  more  quiet  under  its  use.  At  no  time  has  she  shown  any  indica- 
tion of  impending  abortion,  and  though  feeble  and  anaemic,  she  is  able  to 
go  about  and  enjoy  herself  in  a  limited  way. 

Aug.  25.  Fowler's  solution  increased,  so  that  she  takes  rrix,  t.  i.  d. 
Movements  somewhat  lighter. 

Sept.  20.  Gave  birth  to  a  healthy  boy  after  a  sliort  labor. 


CHOREA.  489 

Oct.  10.  Cured.  Discharged.  There  "was  no  special  temperature 
variations  at  any  time. 

A  case  of  interest  is  that  of — 

Lena  C,  ast.  44  ;  Germany  ;  married.  Her  mother  had  chorea  at  the 
same  age.  About  four  years  ago,  without  any  appreciable  cause,  convul- 
sive movements  of  the  whole  body  began.  These  were  not  general  at  first, 
and  were  limited  only  to  the  upper  extremities.  The  movements  are 
bilateral,  and  agitate  the  hands  more  than  any  other  part.  The  facial 
muscles  are  slightly  affected,  and  there  is  a  jerking  upwards  of  the  corners 
of  the  mouth,  more  especially  on  the  right  side.  The  movements  are  neither 
aggravated  nor  controlled  by  the  will,  but  cease  during  sleep.  Her  cutane- 
ous sensibility  is  in  no  way  affected,  and  her  sight  and  hearing  are  both 
good.  She  has  a  strange  habit  of  clutching  her  dress  in  front,  probably 
to  steady  her  hands,  and  when  spoken  to  she  seems  greatly  disconcerted 
and  moves  more  than  ever. 

June  25.  Fl.  ext.  conii,  TIX  xl,  t.  i.  d.  ordered  by  visiting  physician. 

2Qth.  Ko  marked  toxic  effects  of  the  drug  apparent,  except  dilatation 
of  the  pupils ;  and  the  patient  says  that  there  is  a  "  complete  lightness  of 
the  body,"  and  that  "she  could  fly-"  Some  improvement  in  movements. 
With  a  strong  voluntary  effort  the  movements  are  stopped  for  a  time. 

July  10.  Great  improvement ;  patient  can  hold  her  arms  quite  steadily. 
Discharged  at  her  own  request  Dec.  15,  1875. 

She  re-entered  Dec.  22,  18.75.  I  found  the  patient  in  probably  the 
same  state  in  which  she  first  came  into  the  hospital.  She  is  a  spare,  tall 
woman,  very  restless  and  emotional.  She  cannot  express  herself  at  all, 
for  when  she  attempts  to  speak  the  tongue  refuses  to  do  its  part  in  arti- 
culation, and  the  result  is  the  utterance  of  ill-arranged  sounds,  which  are 
not  properly  formed  into  words.  She  smacks  her  lips,  and  "  clicks  "  her 
tongue  against  the  roof  of  the  mouth,  and  the  sounds  which  come  forth 
are  tremulous  and  agitated,  and  just  such  as  one  would  expect  to  hear 
from  a  person  who  was  agitated  by  some  great  fear.  The  contortions  of 
the  arms  are  very  violent  and  irregular,  and  almost  defy  description. 
The  body  seems  to  twist  upon  the  pelvis ;  the  arms  are  thrown  backwards 
and  forwards,  and  the  hands  and  fingers  are  constantly  working.  She 
seems  to  have  no  volitional  control  over  her  limbs,  and  has  very  little 
muscular  force.  She  walks  without  any  apparent  embarrassment,  but 
when  seated  the  movements  in  the  lower  extremities  are  more  active  than 
when  she  stands  up.  She  was  somewhai  analgesic,  as  was  demonstrated  by 
pinching.  Treatmeat  with  strychnine  considerably  moderates  the  violence 
of  the  spasmodic  movements. 

Chorea  may  often  present  a  periodic  character,  especially  if  malaria 
enters  into  its  causation.  The  tendency  to  relapse  is  quite  a  striking 
feature,  and,  in  many  cases  which  I  have  seen,  it  appeared  either  during 
the  early  fall  or  spring,  and  reappeared  the  following  season.  ^  Weir 
Mitchell,  who  has  presented  some  very  interesting  facts  regarding  the  re- 
currence of  chorea  -of  80  cases  collected  by  Dr.  Gerhard,  25  had  attacks 
before — some  of  them  several  times. 

I  have  two  patients  now  under  treatment  who  have  had  attacks  every 
spring  for  the  past  four  years,  but  in  these  as  well  as  other  cases  I  find 

1  Treatise  upon  Diseases  of  the  ]S'ervous  System,  especially  of  Women.    Phila.,  1881. 


490  CEREBRO-SPINAL    DISEASES. 

the  disease  diminishes  in  violence,  and  the  attack  in  duration,  as  it  is  re- 
peated. Mitchell  has  observed  cases  in  which  the  recurrence  of  attacks 
was  irregular,  a  year  or  two  having  intervened  between  them,  and  such 
is  my  experience. 

Chorea  may  be  accompanied  by  other  nervous  troubles,  or  exist  in  an 
uncomplicated  form  as  a  result  of  debility  arising  from  repeated  nervous 
exhaustion  or  fresh  eccentric  causes.  In  one  case  I  found  it  to  appear 
as  soon  as  cold  weather  came,  and  at  the  same  time  an  extensive  eczema 
upon  the  calves  of  the  legs  and  scalp  was  developed.  This  disappeared, 
together  with  the  movements,  under  the  use  of  arsenic  and  oil,  but  both 
reappeared  the  following  winter.  Dr.  E.  Frankel  has  reported  a  similar 
case,  and  I  have  no  doubt  there  are  others  who  have  had  a  like  experi- 
ence. The  disease  usually  wears  itself  out  in  a  short  time,  the  tendency 
to  relapse  rarely  lasting  after  puberty  ;  and  if  a  cure  can  be  effected,  the 
maintenance  of  a  high  standard  of  general  health  and  certain  precautions 
as  to  overwork  or  study  prevent  a  return. 

Causes. — Various  writers  agree  that  the  disease  is  confined  to  the 
period  between  the  third  and  fourteenth  years,  and  this  has  been  my  ex- 
perience. I  do  not  know  of  a  case  under  three  years,  but  others  have 
seen  the  disease  in  younger  children.  Watson  limits  the  time  at 
which  chorea  may  appear  to  the  period  between  the  first  and  second 
dentitions;  and  Hillier  of  Great  Ormond  Street  Children's  Hospital,  has 
given  a  table,  which  is  referred  to  by  Radcliffe.  He  found  that  of  422 
cases  at  the  above  institution,  104  were  between  the  ages  of  ten  and 
twelve.  Niemeyer  believes  the  malady  to  be  very  rare  before  the  sixth 
year  and  after  the  fifteenth.  Girls  seem  to  be  more  often  affected  than 
boys,  for  what  reason  I  cannot  say,  except  that  it  may  be  the  more 
delicate  organization  of  the  former,  and  the  preparative  changes  going  on 
before  menstruation. 

Mitchell  has  gone  to  great  trouble  to  collect  statistics  showing  the  in- 
fluence of  season  and  meteorological  changes.  He  finds  that  March  and 
April  are  the  two  mouths  in  which  the  attacks  are  more  frequent,  con- 
firming the  observations  of  other  writers;  and  that  the  rise  and  fall  of  the 
line  of  humidity  and  temperature  play  a  decided  aggravating  or  modify- 
ing influence.  Mitchell  also  has  ascertained  that  chorea  is  very  rare 
among  the  blacks. 

When  the  disease  appears  after  puberty,  it  generally  takes  an 
eccentric  form,  or  it  may  be  due  to  central  organic  changes,  or  fol- 
low hemiplegia.  This  latter  form,  denominated  by  Mitchell  post-para- 
lytic chorea,  has  already  been  described.  In  chorea  there  is  a  general 
derangement  of  the  digestive  organs  and  loss  of  appetite  and  constipation 
and  palpitation  are  quite  common  alterations  of  function  met  with  in 
these  cases.  In  the  anaemic  patients,  and  they  are  generally  all  so,  there 
is  often  an  aortic  murmur,  and  the  skin  is  pale  and  cool. 

The  existence  of  cardiac  disease  or  the  previous  history  of  rheumatism 
is  considered*  by  many  authors  to  have  much  to  do  with  the  causation  of 
the  disease.     Romberg,  Hughes,  and  West,  besides  many  others,  have  so 


CHOREA.  491 

decided  ;  and  when  we  consider  the  pathology  of  chorea,  it  will  ap- 
pear to  us  very  reasonable.  Of  104  cases  of  chorea  at  Guy's  Hospital, 
but  15  of  the  number  were  free  from  any  indication  of  cardiac  or  rheuma- 
tic difficulties. 

The  disease  often  follows  scarlatina  or  other  zymotic  febriculas,  or  takes 
its  origin  from  an  attack  of  acute  rheumatism,  or  whooping-cough.  It  may 
result,  and  generally  does,  from  some  directly  exciting  causes,  such  as  over 
study,  bad  air,  or  food,  worms,  or  sudden  fright.  My  recent  investigations 
in  regard  to  the  occurrence  of  the  disease  among  school  children  revealed 
the  astounding  fact  that  over  twenty  per  cent,  of  young  school  children  of 
the  public  schools  of  New  York  were  affected  with  choreic  affections  of 
greater  or  less  gravity.^  West  expresses  it  as  his  opinion,  that  over-study 
is  a  common  cause,  and  my  investigations  are  sufficient  to  prove  this. 

Many  cases  are  supposed  to  result  from  association  of  unaffected  chil- 
dren with  those  who  are  the  subjects  of  chorea.  Niemeyer  alludes  to  the 
prevalence  of  this  "  mimetic  form  "  among  boarding-school  pupils.  This 
view  has  been  very  popular  with  the  laity,  and  I  am  convinced  has  some 
importance,  still,  I  cannot  but  think  that  the  influence  of  example  has 
been  grossly  exaggerated. 

Malaria  seems  to  play  a  decided  part  in  the  etiology  of  the  disease. 
This  was  pointed  out  by  Kinnicutt,  who  reported  some  interesting  cases 
in  which  the  movements  were  aggravated  at  certain  hours  on  alternate 
days,  and  were  characterized  by  something  like  periodicity. 

Morbid  Anatomy  and  Pathology. — Comparatively  few  cases  of 
fatal  chorea  have  been  reported.  Twenty-two  of  these  are  brought  for- 
ward by  Dr.  Dickinson,  whose  excellent  article  upon  the  pathology  of 
chorea  deserves  the  attention  of  every  student  of  neurology.  One  case 
has  been  reported  by  Ellischer,^  which  is  instructive,  as  it  exhibits 
changes  in  the  nerve-trunks ;  and  Ogle,^  Kirkes/  Hughes,^  Romberg," 
and  See  ',  have  made  autopsies  in  other  cases.  The  connection  between 
disease  of  the  heart  and  the  neurosis  under  consideration  has  been 
studied  perhaps  most  extensively  on  account  of  the  occurrence  of  rheu- 
matism and  valvular  trouble  as  a  complication  in  many  of  the  cases.  In 
Dickinson's  cases  the  heart  was  found  to  be  healthy  in  five ;  in  the 
remaining  seventeen  the  following  lesions  were  observed : — 

Eecent  vegetations  on  mitral  valves  only, seven. 

"  "  "  "       with  old  thickening,  ....      one. 

^  Am.  Psychological  Journal,  Feb.  1876.  A  number  of  papers  containing  questions 
were  sent  to  the  public  school  teacher.^  of  this  city.  In  most  instances  the  answers 
were  intelligent  and  satisfactory.  The  cases  alluded  to  above  varied  from  movement 
of  the  hands  and  twitching  of  the  facial  muscles  to  general  movements  which  attracted 
the  attention,  of  visitors. 

2  Archiv.  fiir  Path.  Anat.,  etc,  Bd.  Ixi. 

3  Brit,  and  For.  Med.-Chir.  Review,  January,  1868  ;  Med  Times  and  Gaz.,  1S66. 
^London  Med.  Gazette,  1850;  Med.  Times  and  Gaz.,  1863. 

*  Guy's  Hospital  Reports,  vol.  iv.,  1846. 

6  Op.  cit. 

'Referred  to  by  Ziemssen. 


492  CEREBRO-SPIXAL    DISEASES. 

Recent  vegetations  on  mitral  and  aortic  valves, one. 

Recent  vegetation^'  on  mitral  and  aortic  valves,  with  pericardial 

adhesions, two. 

Recent  vegetations  on  mitral  and  tricuspid  valves, one. 

Recent  vegetations  on  mitral  and  tricuspid  valves,  with  pericar- 
dial adhesions one. 

Recent  vegetations  on  mitral  and  aortic  valves,  with  recent  peri- 
carditis,   ." two. 

Recent  vegetations  on  mitial  valves,  with  old  pericardial  adhesions,  one. 

Of  the  patients  affected  with  recent  endocarditis,  the  chorea  in  6  ori- 
ginated from  rheumatism,  in  2  from  mental  causes,  in  3  from  uterine,  in 
1  from  rheumatic  and  uterine,  in  2  from  mental  and  uterine,  and  in  3 
from  unknown  causes ;  thus  showing  the  connection  between  the  rheu- 
matic origin  and  the  cardiac  changes. 

The  brain  and  cord  were  affected  in  11  cases,  there  being  congestion, 
softening,  and  appearances  similar  to  those  noted  by  the  other  observers 
I  have  mentioned. 

In  one  of  his  cases  (No.  V.)  he  made  very  thorough  microscopical 
examinations,  and  I  present  his  account  of  the  appearances  noted :  "  Sub- 
sequently sections  from  almost  every  region  of  the  brain  were  examined 
microscopically.  They  were  in  most  instances  natural,  the  nerve-cells 
invariably  s^,  save  some  injection  of  the  vessels,  not  enough  to  be  de- 
cidedly morbid ;  though  the  veins  were  much  distended,  in  particular 
about  the  dentate  bodies  of  the  cerebellum,  the  vessels  and  their  canals 
were  normal.  There  was  no  extravasation,  effusion,  or  erosion.  Two 
situations,  however,  were  remarkable  exceptions  to  these  statements.  In 
the  deeper  white  matter  of  one  of  the  cerebral  convolutions  were  many 
conspicuous  spots,  which  consisted  of  accumulations  of  crystals  of  hcema- 
tine  mingled  with  indefinite  debris,  probably  of  nervous  origin,  swelling 
the  canals  around  the  arteries  which  still  remained  distended  with  blood. 

"  The  other  region  referred  to  as  the  seat  of  significant  change  is  that 
of  the  corpora  striata.  These  bodies  were  more  minutely  injected  than 
the  rest  of  the  brain.  The  capillaries,  as  well  as  the  larger  vessels  of 
both  classes,  being  packed  with  blood-corpuscles  and  numerous  spots, 
striking  objects  under  the  microscope,  were  closely  set  in  their  substance. 
These  consisted  each  of  an  artery  in  section,  empty,  crumpled  and  col- 
lapsed, and  surrounded  by  a  mass  of  globular  debris,  which  had  been 
formed  at  the  expense  of  the  surrounding  tissue.  They  had  evidently 
been  produced  by  a  solution  or  destruction  of  tissue  around  the  vessel 
consequent  upon  effusion  from  it,  the  result  of  injection  which  had  now 
ceased  to  exist.  In  time  these  mixed  effects  of  extravasation  and  disin- 
tegration would  have  disappeared  and  left  mere  vacuities. 

"The  spinal  cord  displayed  loaded  vessels  and  eroded  fissures,  such  as 
were  seen  in  every  other  instance  examined.  In  addition  to  these  com- 
mon changes,  the  gray  matter  had  undergone  extensive  transformation  of 
the  kind  to  which  the  term  sclerosis  has  been  given.  This  was  slight  in 
the  cervical  region — extreme  throughout  the  dorsal — absent  from  the 


CHOREA.  493 

lumbar.  The  change  was  confined  to  the  gray  matter,  which  it  affected 
on  the  same  side  of  the  cord  nearly  symmetrically.  In  the  dorsal  region 
it  involved  at  least  a  third  of  the  gray  matter  as  seen  in  section ;  the 
affected  portions  on  each  side  being  adjacent  to  the  attachment  of  the 
transverse  commissure,  and  at  the  root  of  each  posterior  horn.  In  the 
cervical  region,  though  the  change  was  less  extensive,  its  position  was  the 
same.  The  altered  gray  substance  had  been  converted  into  a  wool-like 
entanglement  of  curving  areolar  fibers,  among  which  nerve-fibers  could 
be  sometimes  traced,  especially  near  the  edges,  but  from  which  all  other 
nerve-elements  had  disappeared,  leaving  a  mere  confusion  of  connective 
tissue.  The  nuclei  proper  to  the  healthy  structure  were  present,  but  had 
undergone  no  increase,  nor  was  there  any  other  evidence  of  fibroid  or 
connective  new  growth.  The  change  seemed  to  consist  essentially  of  a 
destruction  and  removal  of  the  nervous  elements,  their  fibroid  skeleton 
only  remaining." 

A  fatal  case  of  chorea  was  reported  by  Dr.  Jas.  H.  Hutchinson.^  The 
heart  was  found  affected,  the  aortic  valves  incompetent,  the  leaflets  being 
"swollen  and  softened,"  and  the  aor.a  was  atheromatous  above  the  sinus 
of  Valsalva. 

Ellischer,^  who  made  an  autopsy,  found  that  the  vascular  changes  in 
the  brain  were  marked,  the  wails  of  the  vessels  being  changed,  and  the 
surface  covered  by  dark  granules.  In  certain  places  the  calibre  of  the 
vessels  was  narrowed,  and  there  was  an  accumulation  of  blood-corpuscles, 
and  consequent  effusion  of  the  watery  parts  of  the  blood.  Some  of  the 
vessels  contained  coagula.  The  connective  tissue  about  these  vessels  was 
thickened  and  increased  in  size,  and  contained  yellow  pigment  and 
granulated  nuclei.  The  large  ganglionic  cells  in  the  brain  were  filled 
with  pigment,  and  the  cell  contents  much  changed.  Sections  of  motor 
nerves  exhibited  red  patches  and  destruction  of  nerve-fibers.  These 
changes  show,  then,  great  vascular  alteration,  and  degeneration  of  nor- 
mal nerve-tissue. 

In  regard  to  the  pathology  there  is  much  dispute,  some  observers  con- 
sidering it  to  be  but  a  functional  condition,  while  others  are  well  satisfied 
as  to  its  organic  nature. 

The  original  observations  of  Kirkes  first  demonstrated  the  relation  be- 
tween chorea  and  rheumatism.  Ogle  contends  that  this  relationship  (or 
at  least  the  evidences  of  rheumatismal  causation  in  the  brain,  such  as 
emboli)  is  only  demonstrated  by  fatal  cases.  He  considers  the  excess  of 
fibrin  in  the  blood  to  be  only  the  result  of  the  same  influence  that  pro- 
duces the  chorea,  and  that  the  blood  state,  instead  of  being  a  cause,  may 
be  a  consequence  of  chorea,  the  result  of  tissue  metamorphosis  due  to  ex- 
cessive muscular  action. 

He  raises  a  question  as  to  the  disappearance  of  the  movements,  and 
considers  this  condition  of  affairs  incompatible  with  organic  lesions.    This 

1  Phila.  Med.  Times,  August  5,  1876. 

2  Op.  cit. 


494  CEREBRO-SPINAL    DISEASES. 

objection,  however,  seems  to  lack  force  when  we  remember  that  in  aggra- 
vated cases  the  movements  do  not  stop  during  sleep.  Another  fact  is  to 
be  considered,  and  this  is  the  tendency'  to  relapse  which  the  simplest  cases 
present. 

The  embolic  theory  has  been  advanced  by  nearly  every  investigator, 
and  its  strongest  supporters  are  Broadbent,  Hughliugs  Jackson,  and  Bas- 
tian.  The  original  investigations  of  Kirkes  served  as  a  basis  for  this  new 
theory.  He  found  that  particles  of  fi brine  were  washed  into  the  cerebral 
vessels.  Hughlings  Jackson  located  the  place  of  final  deposit  in  the  gray 
matter  of  the  convolutions  in  the  neighborhood  which  is  supplied  by 
the  middle  cerebral  artery.  Jackson  very  cogently  considers  the  signifi- 
cance of  its  one-sided  character  as  compared  with  hemiplegia  from  embo- 
lism, and  has  since  brought  up  the  question  of  involvement  of  the  mus- 
cles more  concerned  in  special  voluntary  acts,  which  are  likewise  conspi- 
cuously affected  in  certain  forms  of  hemiplegia  and  epilepsy,  with  cortical 
degeneration 

Against  this  theory,  some  writers  have  raised  the  question  in  regard  to 
the  existence  of  the  hemichorea  on  the  same  side  of  the  body  as  that  of 
the  brain  where  the  lesion  is  found,  and  contend  that  there  must  be 
crossed  action.  The  recent  and  conclusive  investigations  of  Flechsig  al- 
luded to  in  other  parts  of  this  book,  show  however,  that  total  decussation 
does  not  take  place  in  the  medulla. 

Dupuy  and  Brown-Sequard  have  made  experiments  which  prove  that 
such  a  condition  of  aft'airs  may  exist,  and  I  have  myself  done  the  same 
thing.  Since  my  experiments,  I  have  heard  of  a  case,  related  by  Dr. 
Walter  Hay,  of  Chicago,  in  which  post-mortem,  examination  revealed  a 
cerebral  hemorrhage  on  the  side  of  the  hemiplegia. 

In  one  of  these  experiments  made  by  Dr.  F.  H.  Rankin  and  myself 
upon  a  monkey,  electrical  irritation  (galvanic)  of  the  white  matter  just 
beneath  the  cortex  of  the  upper  part  of  the  left  ascending  parietal  con- 
volution produced  convulsions  in  both  extremities  of  the  same  side. 

The  views  of  Jackson  now  seem  to  warrant  the  supposition  that  in  a 
very  large  number  of  cases,  in  those  especially  in  which  no  j^ost-mortem 
appearances  were  found ;  or  at  least  have  not  been  hitherto  looked  for  in 
the  region  of  the  cortical  motor  centres  where  they  might  have  existed 
unrecognized ;  that  the  motor  area  of  the  cortex  is  primarily  in  fault.  In 
some  cases  we  are  furnished  with  startling  proofs  of  this. 

A  woman  who  recently  died  at  the  Hospital  for  Epileptics  and  Para- 
lytics, and  who  was  in  my  ward  for  a  number  of  years,  presented  the 
most  aggravated  symptoms  of  chorea  I  have  ever  seen.  Her  disease  had 
lasted  for  twenty  or  thirty  years,  and  before  her  death  there  were  decided 
mental  disturbances  which  occasionally  burst  out  in  attacks  of  mania. 
Her  whole  body  seemed  to  be  affected,  for  every  limb  was  agitated  by  cho- 
reic twitchings.  She  sat  usually  upon  a  low  chair,  her  body  bent  for- 
ward, her  arms  extended,  and  her  fingers  spasmodically  working.  Her 
head  w^as  in  a  constant  state  of  movement,  and  her  li]3s  and  facial  muscles 
were  implicated  as  well.     She  could  not  talk  distinctly,  but  her  utter- 


CHOREA.  495 

ances  were  explosive  and  rapid.  There  never  had  been  any  paralysis, 
but  after  death  the  important  cortical  motor  centres  oti  both  sides  were 
found  to  be  the  seat  of  atrophy.  In  this  case,  which  probably  re- 
sembles others  of  the  same  class,  the  destruction  of  certain  psycho- 
motor cortical  centres  does  not  result  in  paralysis,  but  a  loss  of 
governing  control  upon  the  part  of  the  upper  gray  matter,  while  the 
lower  motor  ganglia  act  independently  and  inharmoniously  in  the  inner- 
vation of  the  muscular  system. 

Broadbent  localizes  the  lesions  entirely  within  the  corpus  striatum.  He 
also  calls  attention  to  the  existence  of  peripheral  irritation,  shock,  and 
various  causes  which  may  produce  a  depraved  functional  condition. 

Bastian  adopts  the  theory  that  the  emboli  consist  of  masses  of  agglome- 
rated white  corpuscles,  and  that  the  location  of  the  lesion  is  in  the  corpus 
striatum. 

Dickinson  is  disposed  to  regard  the  chorea  as  the  result  of  rheumatism 
rather  than  of  endocarditis,  and  considers  the  central  condition  one  of 
hypersemia  of  the  nervous  centres, ''  not  due  to  any  mechanical  mischance, 
but  produced  by  causes  mainly  of  two  kinds  :  one  a  morbid,  probably  a 
humeral,  influence  which  may  affect  the  nervous  centres  as  it  affects  other 
organs  and  tissues ;  the  other,  irritation  in  some  mode,  usually  mental, 
but  sometimes  what  is  called  reflex,  which  especially  belongs  to  and  dis- 
turbs the  nervous  system,  and  afiects  persons  difierently  according  to  the 
inherent  mobility  of  their  nature." 

In  regard  to  localization  he  agrees  in  the  main  with  the  other  observ- 
ers. "  The  spots  of  perivascular  change  are  widely  scattered  throughout 
that  large  region  which  lies  iuferiorly  to  the  cerebral  convolutions  be- 
tween the  corpora  striata  and  the  lower  end  of  the  cord ;  the  district  of 
the  motor  and  sensory  as  distinguished  from  the  mental  functions." 

It  seems,  then,  that  the  quality  of  the  lesion  is  only  disputed.  I  am 
strongly  inclined  to  accept  the  embolic  theoiy,  not  only  because  the  pare- 
sis of  the  limb  may  precede  any  muscular  movements,  but  because  lesions 
in  or  about  the  corpora  striata,  which  produce  hemiplegia,  may  also  give 
rise  to  choreic  movements,  but  I  believe  that  the  motor  zone  of  the  cortes 
is  often  at  first  the  seat  of  pathological  changes. 

Diagnosis. — The  movements  of  chorea  must  be  difierentiated  from 
those  of  sclerosis  and  paralysis  agitans.  This  will  not  be  a  difficult  task, 
as  the  peculiarity  of  the  choreic  movement  is  the  jerh,  while  the  tremor  of 
the  other  affection  is  rhythmical  and  usually  fine,  and  varies  under  certain 
circumstances.  The  rapid  recovery  should  also  be  an  element  in  the  di- 
agnosis. 

That  chorea  may  result  in  some  secondary  disease,  such  as  softening  or 
meningitis,  is  well  settled ;  and  in  these  cases  it  will  be  necessary  to  take 
into  account  the  character  of  all  the  new  symptoms,  and  the  history  of  the 
old  ones. 

The  exceptional  forms  of  the  disease  may  be  mistaken  for  hysterical 
troubles,  and  then  the  diagnosis  will  be  difiicult.  It  must  be  borne  in 
mind,  however,  that  this  mistake  can  be  made  only  in  adult  cases.     The 


496  CEREBRO-SPINAL    DISEASES. 

paralysis  of  chorea  may  be  differentiated  from  true  cerebral  or  spinal  pa- 
ralysis by  its  gradual  development,  and  by  the  age  of  the  individual,  as 
these  two  forms  are  quite  rare  iu  infancy.  Choreic  movements  usually 
stop  at  night,  and  the  exceptions  to  the  rule  of  quiescence  during  sleep 
include  those  in  which  the  patients  have  "dreams  of  movement,"  such  as 
were  alluded  to  by  Marshall  Hall. 

Prognosis. — Chorea  is  an  affection  which  may  very  often  disappear, 
without  any  treatment  whatever,  in  from  six  weeks  to  four  months;  but 
there  are  very  likely  to  be  relapses.  If  properly  treated,  the  movements 
should  disappear  in  from  six  weeks  to  two  months,  or  even  in  a  shorter 
time.  If  the  disease  appears  after  puberty,  the  prognosis  is  unfavorable, 
and  all  we  can  do  in  some  cases  is  to  moderate  its  violence.  There  is 
a  tendency  to  recovery  in  other  cases,  among  them  those  of  pregnancy. 
Death  is  a  very  unusual  termination,  and  it  rarely  occurs  as  a  result  of 
the  disease  itself,  but  rather  of  some  cardiac  complication. 

Treatment. — Internal  remedies  :  Strychnia ;  arsenic  ;  iron  in  its 
various  forms  (bromide,  carbonate,  etc.) ;  phosphorus  and  cod-liver  oil. 
External  remedies :  Cold  to  spine — ice,  ether  spray,  and  cold  douche ; 
Russian  or  Turkish  baths ;  and  salt  baths.     Rest,  diet,  and  fresh  air. 

Some  of  these  may  be  combined  with  good  effect.  The  plan  of  treat- 
ment I  generally  employ  is  the  following:  Should  the  child  be  "run 
down,"  as  is  generally  the  case,  I  begin  with  some  preparation  of  iron, 
and  administer  at  the  same  time  cod-liver  oil.  As  regards  special  treat- 
ment, I  find  strychnine  serviceable,  carried  up  to  the  point  where  stiffness 
of  the  sural  muscles  is  arrived  at.  Next  to  this  stands  arsenic.  It 
must  be  given  in  large  doses ;  but  when  we  find  that  digestive  troubles 
are  produced  very  quickly  by  this  drug,  strychnia  may  be  substituted. 
In  some  cases,  when  gastritis  is  produced,  we  may  use  the  arsenic  in  the 
form  of  Fowlers  solution  hypodermically,  and  larger  doses  may  be  ad- 
ministered in  this  way.  Cold  to  the  spine  cannot  be  overestimated  as  a 
plan  of  treatment.  We  may  either  use  the  ether  spray,  which  was  first 
suggested  for  use  in  this  disease  by  Subet^ki,  of  Warsaw,  in  1866,  or 
apply  ice-bags  every  day,  allowing  them  to  stay  on  about  ten  minutes. 
Perroud,  who  has  used  the  ether  spray,  makes  applications  from  four  to 
eight  minutes  in  duration  every  day.  Of  thirty-five  cases  I  have  treated 
in  this  way  (I  mean  with  the  ether  spray),  from  fifteen  to  twenty  appli- 
cations produced  permanent  benefit ;  and  here  I  would  say  that  the  spray 
should  be  directed  chiefly  to  the  upper  part  of  the  cord,  over  the  upper 
cervical  vertebrae.  Eserine  has  been  recommended,  and  Bouchut  has 
given  the  results  of  437  cases,  205  of  whom  took  it  in  pilular  form, 
and  232  hypodermically.  The  average  dose  was  from  two  to  five  milli- 
grammes. He  obtained  temporary  benefit,  which  seemed  to  wear  off; 
but  when  the  drug  was  repeatedly  administered,  he  accomplished  many 
cures.  He  reports  twenty-three  cures  by  an  average  of  seven  injections. 
It  is  a  dangerous  remedy,  however,  and  produces  severe  gastric  symptoms. 

The  salts  of  zinc  have  occasionally  proved  valuable  in  cases  of  this  dis- 
ease ;  and  conium  is  occasionally  eflBcacious,  but  its  effects  are  tempora- 


CHOREA.  497 

ry ;  but  I  prefer  the  remedies  I  have  mentioned.  I  have  found  phospho- 
rus, with  cod-liver  oil,  to  be  a  most  valuable  curative  agent,  and  in  cases 
where  everything  else  failed  it  has  succeeded.  This  seems  reasonable, 
when  we  consider  how  much  impaired  must  be  the  nutrition  of  the  nerv- 
ous matter. 

Da  Costa^  and  Mills,^  of  Philadelphia,  have  used  the  bromide  of  iron  ; 
but  the  latter  has  had  very  successful  results.  In  twelve  patients  to 
whom  he  administered  the  drug,  there  was  no  improvement  after  its  use. 

Dr.  Mills  says :  "  It  was  usually  given  in  plain  syrup  and  water,  com- 
mencing with  five  grains  three  times  daily,  as  recommended,  and  rapidly 
increasing  the  dose  to  twenty.  The  treatment  was  continued  from  two  to 
four  weeks.  Twenty  grains  very  generally  caused  vomiting.  It  seems 
to  be  a  remedy  which  quickly  irritates  the  intestinal  tract." 

Oulment  and  Laurent  recommended  hyoscyamin  in  doses  of  one-six- 
tieth of  a  grain,  in  pill  form,  at  first  twice  daily,  and  afterwards  more 
frequently.  Amelioration  is  said  to  begin  in  eight  or  nine  days  for  a 
child.  I  have  administered  hyoscyamin  to  a  number  of  cases  with  great 
benefit.  It  is,  however,  a  most  dangerous  remedy,  and  the  commencing 
dose  should  not  be  more  than  sho  of  a  grain,  to  be  increased  if  dryness  of 
the  mouth  and  dizziness  are  not  too  great.  Should  the  presence  of  worms 
be  suspected,  we  may  either  use  an  injection  of  quassia  and  carbolic  acid 
solution  (gtt.  X — Oj)  after  each  stool,  or  pursue  the  ordinary  santonine 
.  treatment.  The  use  of  ferruginous  tonics  is  generally  indicated,  and  those 
should  be  selected  which  are  best  assimilated  and  which  tax  digestion 
the  least.  I  would  therefore  recommend  either  the  carbonate  of  iron,  or 
dyalized  iron.  The  addition  of  digitalis  seems  to  increase  their  good 
effects  quite  materially.  Chalybeate  waters  are  useful,  and  sulphur  baths 
are  recommended  by  Baudelocque  and  others. 

Trousseau  recommends  morphine  and  strychnine,  but  I  have  never 
seen  any  good  results  follow  the  use  of  the  former ;  of  the  virtues  of  the 
latter  I  have  already  spoken.  H.  C.  Wood  recommends  a  tincture  made 
from  the  fresh  leaves  of  the  skunk-cabbage,  with  which  he  has  had  some 
success.  Electricity  I  have  no  faith  in,  except,  perhaps,  when  the  so-called 
"  general  electrization  "  is  used  as  a  cutaneous  and  muscular  stimulant. 
Benedikt  has  cured  many  cases  by  galvanism;  but,  as  far  as  I  can  learn, 
his  results  are  exceptional. 

There  are  instances  where  nothing  does  good.  It  is  well  to  put  the 
patients  in  a  dark  room,  and  keep  them  perfectly  quiet.  We  will  be 
often  astonished  at  the  result.  There  are  little  things  that  must  be 
watched.  The  diet,  above  all  things,  should  be  regulated  with  judgment. 
Plenty  of  fresh  air  and  sleep  come  next,  and  absolute  mental  rest  must 
be  enforced.  The  school-books  and  the  school-room  are  to  be  parted  from,, 
and  agreeable  diversions  planned.  An  excellent  auxiliary  to  our  medi- 
cation is  the  salt-bath.   A  handful  of  rock-salt  in  the  water,  and  the  ener- 

1  Med.  and  Surg.  Eeporter,  Jan.  30,  1875. 

2  Phila.  Med.  Timea,  Sept.  25,  1875. 
32 


498  CEREBRO-SPINAL    DISEASES. 

getic  use  of  the  rough  towel,  will  infuse  a  tone  and  vigor  that  will  soon 
become  apparent.  In  conclusion,  I  must  say  that  decided  medication  is 
useless  in  these  patients  if  their  personal  habits  are  not  looked  after. 

PAKALYSIS  AGITANS. 

Synonyms. — Shaking  palsy ;  Parkinson's  ^  disease ;  Trembling  palsy ; 
Tremblement  senile;  Chorea  senile;  Chorea  festinans. 

It  is  unfortunate  that  so  much  confusion  exists  in  regard  to  the  proper 
classification  of  this  tremor  of  old  age.  It  has  been  and  is  to  this  day 
confounded  with  cerebro-spinal  sclerosis. 

I  shall  speak  of  it  as  a  disease  of  advanced  life,  symptomatized  by  paresis, 
involving  usually  the  upper  extremities,  with  tremor  which  is  not  increased 
by  voluntary  muscular  action.  This  tremor  rarely  affects  the  muscles  of 
the  face,  except  in  advanced  stages  of  the  disease,  and  is  accompanied  by 
festination,  and  in  certain  cases  by  bending  of  the  body  forwards,  and 
inclination  of  the  chin  forwards  and  downwards. 

Symptoms. — The  extremities  first  become  the  seat  of  tremor,  the  fin- 
gers being  agitated  in  the  beginning;  the  hand  is  next  involved,  and  after- 
ward the  arm.  This  tremor  is  bilateral,  and  it  may  not  make  further 
advances  for  some  time,  but  ultimately  the  head,  and  other  limbs  are 
included.  The  tremor  may  involve  one  hand  before  the  other,  or  the  leg 
of  the  same  side  may  be  next  affected,  then  the  leg  of  the  other  side,  and 
next  the  opposite  arm.  After  a  variable  time,  extending  from  one  to  ten  • 
years,  a  species  of  muscular  rigidity  takes  place,  so  that  the  head  is  drawn 
down,  and  ultimately  the  body  is  bent  and  the  head  is  thrust  forwards,  or 
the  chin  is  drawn  down  to  the  breast.  The  forearms  and  hands  are  flexed, 
and  the  arms  may  be  drawn  to  the  side  of  the  body.  The  constant  move- 
ments may  produce  an  actual  abrasion  of  the  skin  by  friction  of  the  elbows 
or  hands,  should  the  muscular  contraction  bring  them  in  contact  with  the 
body.  Any  attempt  at  locomotion  is  attended  by  what  has  been  called 
"  festination."  The  patient  may  rise  slowly  from  his  seat,  and  perhaps 
in  the  early  stages  walk,  slowly  though  awkwardly,  by  taking  long  strides, 
but^when  the  muscles  of  the  back  lose  their  power,  and  the  body  pitches 
forward,  the  patient's  attempts  to  preserve  his  equilibrium  result  in  a 
shuffling  gait,  and  finally  he  is  compelled  to  run  and  gladly  clutches  the 
nearest  chair  or  support  to  avoid  falling. 

The  voice  is  weak  and  the  speech  broken  and  abrupt,  and  the  form  of 
interruption  has  been  compared  by  Charcot  "to  that  which  affects  a  novice 
in  equitation  when  his  horse  begins  to  trot."  This  interruption  is  caused 
by  the  violence  of  the  muscular  movements.  The  patient  pitches  his 
voice  when  he  begins  to  speak,  and  never  changes  the  tone  until  he  has 
finished,  so  that  his  phonation  is  decidedly  monotonous.  He  is  greatly 
fatigued  by  the  constant  muscular  movements,  and  is  restless  and  inclined 
to  seek  new  positions  which  may  give  him  ease.  A  disagreeable  symptom 
is  the  occurrence  of  cramps  of  temporary  duration,  which  are  more  com- 

^  Essay  on  Shaking  Palsy,  London,  1817. 


PARALYSIS  AGITANS.  499 

mon  during  the  day.  During  the  tremor  the  fingers  or  toes  may  be 
rigidly  flexed  or  extended.  The  face  is  utterly  devoid  of  expression,  but 
the  mind  is  never  impaired,  and  there  are  no  affections  of  the  organs  of 
special  sense.  The  tremor  in  the  beginning  ceases  at  night,  but  in  the 
established  form  it  is  present  at  all  times. 

The  termination  of  the  disease  may  be  in  death  through  exhaustion  or 
complicating  diseases,  such  as  pneumonia,  which  carried  off  three  cases 
reported  by  Trousseau.  The  functions  of  the  bladder  and  rectum  are  not 
usually  involved,  except  when  the  disease  has  become  confirmed.  In  one 
case  Topinard  found  sugar  in  the  urine,  but  it  is  hardly  necessary  to  say 
that  this  circumstance  is  exceptional. 

After  suffering  for  a  number  of  years  the  patient  is  finally  obliged  to 
seek  his  bed,  sloughs  form  over  the  sacrum,  and  he  gradually  sinks,  the 
tremor,  perhaps,  moderating  slightly  before  death. 

The  following  interesting  case  is  one  that  illustrates  the  course  of  the 
disease  perfectly : — 

Mr.  M.,  the  patient,  during  his  early  years  led  an  active  life,  and  after 
following  the  occupation  of  a  peddler  gradually  worked  his  way  up  to 
prosperity.  For-years  he  went  about  the  streets  of  New  York  carrying, 
many  hours  in  the  day,  a  heavy  pack  upon  his  back,  and  during  this  time 
he  suffered  many  privations  of  food,  rest,  and  sleep,  and  was  exposed  to 
the  elements,  after  going  home  wet  and  cold.  About  fifteen  years  ago  he 
first  noticed  the  appearance  of  his  present  disease.  He  is  a  stout  man  of 
large  frame,  and  about  70  years  old.  The  trembling  began  after  slight 
exertion,  and  continued  for  some  time.  It  became  more  pronounced  and 
constant  during  the  next  two  or  three  years,  and  he  was  unable  to  un- 
button his  clothing,  feed  himself,  or  use  his  hands.  His  general  health 
did  not  seemingly  suffer,  but  he  was  "  nervous"  and  depressed,  and  fully 
aware  of  his  pitiable  state.  He  did  not  tremble  so  much  when  lying  down, 
but  when  he  moved  about  or  assumed  the  erect  position  the  hands  shook 
and  the  head  shook  constantly  from  side  to  side.  The  movements  always 
stopped  at  night,  but  it  was  some  time  before  he  could  sleep.  He  gradu- 
ally lost  power;  the  right  arm  losing  strength  primarily,  and  afterwards 
the  left.  Coincident  with  the  loss  of  power  there  was  tremor.  When  I 
saw  him  two  years  ago,  I  found  him  seated  in  a  chair  in  which  he  had 
difficulty  in  keeping  his  place.  His  upper  extremities  and  head  were 
chiefly  affected.  The  head  was  inclined  forwards,  and  was  constantly 
agitated  by  movements  of  a  rhythmical  character,  which  did  not  appear  to 
be  increased  or  diminished  by  any  act  of  volition.  He  could  not  raise  his 
chin,  but  looked  up  at  me  when  I  entered  the  room  with  his  son.  When 
asked  a  question,  he  answered  in  a  tremulous  voice,  speaking  as  would  one 
who  was  chilled.  His  body  was  curved  forwards,  and  his  arms  were  semi- 
flexed, the  elbows  being  drawn  to  the  chest;  and  forcible  or  voluntary 
extension  was  impossible.  There  was  no  atrophy  of  the  muscles  of  the 
arms  or  forearms,  and  no  d-^cided  loss  of  sensation.  The  hands  were  agi- 
tated by  the  same  rhythmical  tremors  as  the  head.  When  he  was  lifted  up 
he  could  not  walk,  and  would  have  pitched  forward  if  not  held.  In  this 
position  I  noticed  that  the  knees  were  also  affected  by  the  tremor.  His 
bladder  and  rectum  did  not  seem  to  be  involved,  at  least  not  as  a  result 
of  the  disease,  for  beyond  symptoms  of  enlarged  prostate  he  suffered  no 
impairment  of  function.     For  the  past  two  years  he  has  needed  powerful 


500  CEREBRO-SPINAL    DISEASES. 

opiates  to  procure  sleep,  the  movements  continuing  unless  they  are  given. 
He  swallows  with  difficulty,  and  there  is  a  drain  of  saliva  from  the  corner 
of  his  mouth.  As  far  as  I  can  learn  there  have  heen  no  disorders  of  the 
organs  of  special  sense,  and  certainly  there  are  now  none.  His  mind 
seems  to  be  somewhat  affected,  as  he  is  irritable  and  silly,  and  his  memory 
is  deficient. 

It  may  be  stated  that  the  affection  may  exist  in  a  modified  form  (Par- 
kinson's disease;  and  that  tremor  alone  may  be  the  only  symptom. 
Festination  and  rigidity  are  by  no  means  constant  expressions  of  the 
affection. 

Causes — Nothing  is  known  in  regard  to  the  causes  of  paralysis  agi- 
tans.  It  has  followed  mental  distress,  or  has  been  preceded  by  neuralgia 
and  rheumatism,  but  these  seem  to  be  connected  with  so  many  nervous 
diseases  that  it  is  difficult  to  say  just  how  much  they  have  to  do  with  the 
etiology  of  paralysis  agitans.  I  have  seen  several  cases,  and  in  none  of 
them  was  there  any  history  of  predisposing  or  exciting  causes.  We  know 
that  the  disease  is  rare  before  the  fortieth  year,  and  that  the  male  sex  is 
more  often  affected  than  the  other  sex. 

Morbid  Anatomy  and  Pathology. — Handfield  Jones  ^  holds 
to  the  doctrine  that  the  affection  is  purely  of  a  functional  character  while 
others  believe  it  to  be  a  multiple  cerebral  sclerosis.  In  an  excellent  re- 
view of  the  recent  writings  of  Charcot  and  Moxon,  which  has  appeared 
lately,  the  reviewer  says :  "  There  is  a  certain  satiric  humor  in  Professor 
Charcot's  notice  of  the  morbid  anatomy  of  paralysis  agitans.  He  divides 
the  autopsies  hitherto  made  into  three  groups.  In  the  first  group  nothing 
at  all  was  found.  The  second  group  comprises  cases  of  supposed  paraly- 
sis agitans,  which  Prof.  Charcot  considers  were  in  reality  sclerosis ;  and 
the  third  group  contains  the  case  of  Parkinson  subsequently  mentioned, 
and  a  similar  case  by  Oppolzer,  which  is  treated  with  similar  distrust. 
There  are,  however,  other  cases  on  record  which  give  much  more  satis- 
factory results.  Leyden  has  reported  one  in  which  the  agitation  was 
limited  to  the  right  arm,  and  a  sarcoma  the  size  of  a  large  nut  was  found 
in  the  optic  thalamus  of  the  opposite  side.  Murchison  and  Cayley  have 
reported  a  case  in  which  very  definite  changes,  partly  of  sclerosis  and 
pai'tly  of  cell  growth,  were  found  in  the  cord  ;  but  as  in  this  case  the 
symptoms  are  described  but  very  briefly,  it  is  possible  that  Prof.  Charcot 
would  place  it  in  his  second  group.  Joffroy,  however,  took  especial  care 
to  investigate  this  point,  as  to  whether  the  cases  were  really  paralysis 
agitans  or  insular  sclerosis,  and  he  states  that  two  out  of  his  three  cases 
were  clearly  paralysis  agitans.  In  these  two  cases  there  was  exuberant 
growth  of  the  epithelium  of  the  central  canal  and  of  the  nuclei  around. 
In  the  third  case,  which  seems  not  to  have  been  a  very  doubtful  one,  there 
was  in  addition  a  sclerosed  patch  in  the  medulla."  ^ 

The  pathology  of  tremor  is  still  so  imperfectly  understood,  and  there  is 

1  Functional  Nervous  Diseases,  p.  382. 

■^  Brit,  and  For.  Med.-Chir.  Rev.,  Oct.  1875. 


PARALYSIS   AGITANS.  501 

SO  much  to  be  said,  that  it  would  involve  a  mucli  more  protracted  consi- 
deration than  the  size  of  this  book  will  permit.  We  may,  however,  con- 
sider some  of  the  physiological  conditions  of  muscles  which,  when  dis- 
turbed, result  in  the  pathological  state  known  as  tremor. 

The  variation  or  interruption  of  any  compound  entity  is  followed  by 
an  inharmonious  relation  of  its  parts  ;  thus  a  musical  sound  is  the  result 
of  a  number  of  more  or  less  rapid  vibrations  and  waves,  their  number 
influencing  pitch.  If  a  catgut  string  in  a  state  of  tension  is  twanged, 
vibrations  are  induced  and  a  musical  tone  is  produced  ;  but  if  a  stick  be 
loosely  held  against  the  string,  without  actual  pressure  being  made,  the 
vibrations  will  be  interrupted,  and  a  discordant  noise  will  be  the  result 
of  such  contact.  It  has  been  demonstrated  that  a  visible  muscular  con- 
traction is,  after  all,  the  result  of  an  incredible  number  of  smaller  con- 
tractions, which  cannot  be  seen  with  the  naked  eye,  but  may  easily  be 
appreciated  with  the  aid  of  the  myographium  or  some  other  registering 
instrument.  Upon  faradizing  a  muscle  this  may  be  experimentally  de- 
monstrated. Shorts  breaks  are  followed  by  visible  contractions  of  the 
muscle  and  movements  of  the  limb  ;  but  if  by  a  proper  current-breaker 
this  interruption  be  repeated  many  hundred  times  a  minute,  the  intervals 
will  be  so  short  that,  though  an  immense  number  of  rapid  contractions 
take  place,  there  is  but  one  grand  contraction  of  the  muscle  which  is  ap- 
preciable. 

In  the  physiological  state  this  co-ordination  (if  I  may  use  the  word)  of 
the  minor  contractions  is  so  perfect  that  the  mu?cular  movements  are 
steady  and  separated  by  regular  intervals  ;  but  when  the  rhythm  is  lost, 
or  the  harmony  destroyed,  the  smaller  contractions  will  be  separated  by 
intervals  of  sufficient  length  to  be  seen,  and  tremor  results,  the  degree  of 
tremor  being  proportionate  to  the  length  of  the  interval. 

The  filaments  of  a  tired  muscle,  the  motor  centres  being  worn  out,  do 
not  contract  evenly  ;  so,  as  a  consequence,  there  is  a  visible  tremulous- 
ness.  In  functional  tremor,  such  as  characterizes  the  disease  in  question, 
this  is  undoubtedly  the  pathological  condition. 

Diagnosis. — The  treatment  of  cerebro-spinal  sclerosis  may  be  mis- 
taken for  that  of  paralysis  agitans.  Let  us  compare  the  points  of  dif- 
ference : — 

PARALYSIS  AGITANS.  CEREBRO-SPINAL  SCXEROSIS. 

Tremor  continues,  but  not  increased  by  Tremor  subsides  during  repose,  and  is 
voluntary  efforts.  always  aggravated  by  volitional  attempts 

at  control. 
Tremor  regular  and  ''  fine.''  Tremor  ''  coarse.'' 

Facial  muscles  unaffected.  Usually  cranial  nerve  paralysis,  or  tre- 

mor of  facial  muscles. 
Kuns  forward  to  preserve  balance.  Only    staggers    wben   walking    is   at- 

tempted. 
Speech  slow,  or  affected  by  violence  of        Speech-defects  those  which  arise  from 
muscular  movements.  paralysis. 

A  disease  of  old  age,  or  advanced  Usually  a  disease  which  appears  before 
life.  middle  age. 


502  CEREBR0-8PINAL    DISEASES. 

Mercurial  tremor,  lead  tremor,  and  alcoholic  tremor  sometimes  resem- 
ble that  of  the  disease  in  question  ;  the  former  is,  however,  more  violent 
in  the  morning ;  the  tremor  from  lead  is  attended  usually  by  colic  and 
other  symptoms  of  plumb  ism  ;  while  no  doubt  need  arise  in  regard  to  the 
third,  which  is  attended  by  evidences  of  alcoholism.  Post- paralytic  cho- 
rea may  be  excluded  by  the  history  of  hemiplegia  or  some  other  equally 
prominent  organic  condition,  and  the  tremor  is  aggravated  by  voluntary 
efforts.  A  functional  tremor  of  a  very  light  grade,  which  is  simply  a 
personal  peculiarity,  is  met  with  sometimes,  and  should  not  be  magnified 
to  the  dignity  of  a  disease.  This  may  affect  several  members  of  the  same 
family,  as  is  the  case  in  one  example  of  which  I  know.  The  head  of  the 
family  is  a  vestryman  of  a  church,  and  in  passing  the  plate  he  sometimes 
is  obliged  to  exercise  the  utmost  self-control  to  prevent  the  contents  from 
being  thrown  out,  and  more  than  once  this  infirmity  has  given  rise  to  in- 
sinuations concerning  his  habits.  His  two  children,  both  very  young  and 
healthy  people,  are  affected  by  the  same  tremor.  In  such  a  ease  the  trou- 
ble does  not  increase  with  time,  and  there  are  none  of  the  other  progres- 
sive signs  of  the  true  affection. 

Prognosis. — The  course  of  paralysis  agitans  is  decidedly  progressive, 
though  very  gradual,  and  the  individual  may  live  for  ten,  twenty,  or  even 
thirty  years  after  the  appearance  of  the  tremor.  When  death  takes  place, 
it  is  in  nine  cases  out  of  ten  the  result  of  some  other  disease.  I  am  con- 
vinced that  genuine  paralysis  agitans  is  never  cured,  though  it  may  be 
relieved ;  and  it  is  highly  important  to  distinguish  simple  functional  tremor, 
which  is  not  uncommon,  from  the  disease  under  consideration.  This  func- 
tional disorder  is  amenable  to  treatment. 

Treatment. — Handheld  Jones ^  considers  that  nothing  can  be  done 
for  the  disease  among  very  old  people  when  it  has  become  decidedly 
chronic.  He  has  used  electricity,  conium,  and  a  variety  of  remedies. 
"  The  general  tenor  of  experience  in  this  and  in  kindred  disorders  is  to 
the  effect :  (1)  that  the  main  indication  is  to  nourish  and  support  the  fail- 
ing power  of  the  nervous  centres  affected  ;  (2)  that  this  is  best  accom- 
plished by  remedies  drawn  from  the  class  of  sedatives,  or  by  the  milder 
tonics.  Henbane,  conium,  chloral,  subcataueous  opiates,  bromide  of  po- 
tassium, belladonna,  hypophosphites,  or  phosphorus,  cod-liver  oil,  carbon- 
ate of  iron,  and  sulphuret  of  potassium  baths,  with  electricity  in  one  or 
other  of  its  three  forms,  appear  to  me  the  most  hopeful  remedies.  But 
steady  persistence  in  appropriate  treatment  is  doubtless  essential,  and  the 
want  of  this  may  account  for  many  failures.  Trousseau's  adage  should  be 
borne  in  mind,  '  A  longue  maladie,  longue  traitement.'  " 

He  refers  to  a  cure  reported  by  another  observer.  The  patient  was  a 
woman,  eighty  years  old,  in  whom  the  disease  followed  severe  labor;  and 
she  was  ultimately  unable  to  carry  trays  or  heavy  loads.  Thefaradic  cur- 
rent used  several  times  effected  the  disappearance  of  the  tremor.     I  am 

1  Brit.  Med.  Journal,  March  8,  1873. 


EXOPHTHALMIC    GOITRE.  503 

inclined,  however,  to  consider  this  case  one  of  functional  tremor,  and  not 
of  the  grave  variety  I  have  described. 

I  have  used  conium  with  good  results,  and  find  that  it  relieves  the  pa- 
tient, but  after  the  use  of  the  drug  has  been  discontinued  for  a  few  weeks, 
the  tremor  is  pretty  sure  to  reappear.  It  should  be  given  in  doses  of  the 
fluid  extract  of  from  n^^  v-^L  viij  thrice  daily. 

Hyoscyamin,  a  remedy  that  possesses  virtues  second  to  none  as  a  de- 
presso-motor,  is  worthy  of  a  trial  in  this  affection,  although  in  chronic 
cases  its  good  effects  are  rarely  more  than  temporary. 

Elliotson^  has  cured  a  case  by  the  carbonate  of  iron  iu  large  doses,  and 
strychnine  has  been  suggested,  but  it  is  doubtful  whether  it  does  any  real 
good. 

Galvanization  of  the  spine,  one  pole  placed  over  the  spine,  and  the 
other  as  near  as  possible  to  the  point  of  exit  of  the  spinal  nerves,  has  been 
advised ;  and  in  some  instances  it  has  improved,  if  it  has  not  cured,  the 
affection. 

EXOPHTHALMIC  GOITRE. 

Synonyms. — Basedow's  disease;  Graves'  disease;  Exophthalmic 
cachectique ;  Cardiogmus  strumosus. 

This  interesting  disease  has  received  but  little  attention  until  within  a 
few  years,  and  it  is  only  lately  that  it  has  been  considered  as  a  neurosis. 

Definition. — Exophthalmic  goitre  is  a  disease  connected  with  vascu- 
lar excitement  and  circulatory  disturbance ;  there  is  not  only  enlargement 
of  the  thyroid  gland,  but  an  excessive  engorgement  of  the  intra-orbital 
vefcsels,  so  that  the  eyeballs  are  pressed  forward,  giving  rise  to  a  hideous 
deformity. 

Symptoms. — The  first  symptoms  of  the  disease  are  generally  indi- 
cated by  violent  action  of  the  heart,  and  great  acceleration  in  the  circu- 
lation; and  with  this  there  is  hypersemia  of  the  cerebral  vessels.  Pal- 
pitation and  pain  over  the  left  side  of  the  chest,  shortness  of  breath,  and 
flushing  of  the  face  are  other  symptoms  of  this  early  stage.  This  early 
vascular  disturbance  is,  perhaps,  the  first  .evidence  of  the  disease  noticed 
by  the  patient,  but  the  enlargement  of  the  thyroid  gland  may  have  been 
progressing  for  some  time.  There  may  be  other  early  symptoms  which 
appear  with  increased  growth  of  the  goitre,  and  protrusion  of  the  eye- 
balls. These  are  falling  out  of  the  hair  of  the  eyebrows,  as  well  as  the 
eyelashes. 

The  heart's  action  is  violent  throughout  the  disease,  and  the  pulse  may 
beat  from  120  to  140  per  minute ;  while  the  temperature  is  one  or  two 
degrees  higher  than  the  normal  standard.  There  is  nearly  always  a  sys- 
tolic bruit  and  a  carotid  murmur.  The  hand,  when  placed  over  the 
goitre,  may  receive  a  peculiar  sensation,  which  is  produced  by  the  agi- 
tation of  the  thyroid  by  the  rapidly  circulating  blood  in  the  enlarged 
vessels. 

^  Quoted  by  Jaccoud,  op.  cit.,  vol.  i.,  p.  427. 


504  CEREBRO-SPINAL    DISEASES. 

Although  the  disease  begins  suddenly  in  some  instances,  it  is  usually  of 
slow  development,  and,  according  to  Eulenburg,  there  may  be  hysterical 
manifestations  before  the  pulse  acceleration  manifests  itself.  I  have  my- 
self noticed  that  the  patients  then  seen  were  emotional  and  easily  excited. 

Digestion  is  nearly  always  impaired,  and  there  may  he  some  diarrhoea 
or  attacks  of  vomiting ;  while  sleep  is  troubled,  and  the  patient  suffers 
greatly  for  want  of  rest.  His  appearance  is  unmistakable.  One  or  both 
eyes  are  prominent,  and  uncovered  by  the  lids ;  and  the  sclerotic  is  ex- 
posed above  the  cornea  to  a  great  extent.  The  patient  is  hypermetropic, 
and  suffers  considerably  from  conjunctivitis  produced  by  the  irritation  of 
foreign  bodies  which  lodge  there. 

There  is  rarely  any  visual  disturbance,  although  troubles  of  accom- 
modation are  met  with  ;  and  there  are  no  changes  to  be  observed  in  the 
retina. 

Dr.  Yeo  reports  two  very  valuable  cases,  which  are  presented  in  admi- 
rable shape  in  a  late  number  of  the  British  Medical  Journal}  In  one 
of  these  there  was  exophthalmos  of  the  left  eye  only,  the  goitre 
being  on  the  right  side.  The  second  case  was  thus  described  by  Dr. 
Yeo :  "  The  patient  is  a  young  single  woman,  23  years  of  age,  robust  and 
strong-looking.  She  shows  no  signs  of  the  pronounced  cachexia  (phthisi- 
cal) so  evident  in  the  other  patient.  But  she  is  especially  interesting 
now,  as  being  also  the  subject  of  unilateral  exophthalmos.  In  her  case 
the  right  eye  only  is  prominent.  There  is  very  little,  if  any,  enlargement 
of  the  thyroid,  but  there  is  constant  palpitation.  The  pulse  has  varied 
during  the  time  she  has  been  under  observation  from  116  to  140.  She 
comes  of  a  healthy  family,  and  has  always  had  good  health  till  lately. 
She  first  noticed  the  prominence  of  the  right  eye  about  a  year  ago.  All 
this  time  she  has  been  feeling  nervous  and  excitable.  She  came  to  King's 
College  Hospital  about  nine  mouths  ago  complaining  of  pains  in  the  back 
of  the  head  and  palpitation.  She  stated,  also,  that  she  suffered  frequently 
from  '  bilious  attacks,'  attacks  of  vomiting  which  would  last  a  whole  day, 
after  which  her  throat  would  get  very  large.  She  complained,  also,  of 
frequent  profuse  perspirations  coming  on  twice  and  three  times  a  day, 
sometimes  without  any  cause  and  sometimes  on  the  slightest  exertion. 
The  hands  and  feet  are  always  perspiring,  and  her  hair  is  sometimes 
wringing  wet"  She  is  easily  fatigued,  has  lost  her  appetite,  and  is  much 
thinner  than  she  used  to  be.  She  suffers  much  from  dysmenorrhoea,  and 
all  her  symptoms  are  worse  at  her  periods.  She  says  her  throat  was  much 
more  enlarged  nine  months  ago  than  it  is  now. 

There  may  be  double  exophthalmos  or  single,  but  the  double  affection 
of  the  eyes  is  the  rule  in  the  great  proportion  of  cases.  In  some  cases  it 
is  absent  entirely,  and  of  58  cases  reported  by  Von  Dusch  it  was  absent 
in  four. 

The  eyeball  may  be  pressed  back,  as  the  vascular  cushion  behind  is 


1  March  17,  1877. 


EXOPHTHALMIC    GOITRE. 


505 


soft  and  yielding;  and  a  peculiar  thrill  is  felt.  An  "  arcus  senilis" 
has  repeatedly  been  observed  by  Bartholow/  who  first  called  attention 
to  this  change,  and  by  others  afterward,  among  them  Thomas.'''  Von 
Graefe  was  the  first  to  allude  to  the  peculiar  behavior  of  the  upper  lid, 

Fig.    65. 


Dr.  Yeo's  Case  of  Exophthalmic  Goitre. 

which,  as  Eulenburg  expresses  it,  "  loses  its  power  to  move  in  harmony 
with  the  eyeball  in  the  act  of  looking  up  or  down."  Irritability  of  tem- 
per, hysteria,  laryngeal  trouble,  and  difficulty  of  breathing  are  symptoms 
which  are  to  be  noticed,  and  towards  the  end  this  respiratory  embarrass- 
ment becomes  quite  distressing. 

The  patient  is  generally  badly  nourished,  and  we  may  have  added  to 
the  symptoms  already  described,  many  of  those  of  general  ansemia. 

The  skin  of  the  whole  body  may  sometimes  be  of  a  much  darker  hue 
than  it  is  in  a  condition  of  health,  and  some  discoloration  of  that  covering 


^  Chicago  Journal  of  Nervous  and  Mental  Diseases,  July,  1875. 
^  Richmond  and  Louisville  Med.  Journ.,  Nov.  1876. 


506  CEKEBRO-SPIXAL    DISEASES. 

the  forehead  is  often  noticed.  This  discoloration  resembles  a  brown  stain, 
and  it  has  been  spoken  of  as  "  bronze  skin  "  by  some  writers.  Raynaud' 
has  called  attention  to  the  connection  between  this  stain,  or  vitiligo,  and 
exophthalmic  goitre.  He  gives  "five  cases  of  exophthalmic  goitre,  culled 
from  various  sources,  in  the  course  of  which  patches  of  vitiligo  appeared 
on  various  parts  of  the  body.  Beyond  the  observation  that  vitiligo  is 
more  common  in  men  than  in  women,  except  when  congenital,  that  it 
attacks  by  preference  persons  of  dark  complexion,  that  it  is  sometimes, 
though  rarely,  hereditary,  and  has  a  certain  analogy  to  Addison's  disease, 
viewed  as  an  imperfect  vitiligo,  little  has  been  made  out  with  regard  to 
its  pathology.  Mr.  Hutchinson  has  pointed  out  that  although  no  known 
cachexia  appears  to  set  up  a  predisposition  to  the  affection,  the  symmetry 
of  the  cutaneous  patches  is  suggestive  of  some  pre-existing  general  fault 
of  the  circulatory  or  nervous  systems,  and  is  opposed  to  the  hypothesis  of 
a  parasitic  origin.  Without  offering  any  explanation  of  the  coexistence 
of  vitiligo  with  exophthalmic  goitre.  Dr.  Raynaud  thinks  that  the  coinci- 
dence should  not  be  allowed  to  pass  unnoticed." 

The  connection  of  urticaria  ha.s  been  pointed  out  by  Bulkley,  who 
reports  two  cases  of  the  disease.     One  of  these  is  presented  : — 

"  Mrs.  — ,  aged  45,  was  delicate  and  sickly  when  a  child.  Was  married 
at  18  years  of  age,  but  separated  from  her  husband  after  4  months  ;  she 
had  a  miscarriage  at  3  months,  and  has  never  been  completely  well  since. 
She  is  of  full  habit ;  bowels  and  menses  regular;  tongue  coated;  pulse 
84,  weak  ;  has  had  chronic  rheumatism. 

"The  history  of  the  Graves'  disease  dates  back  a  number  of  years — at 
least  five  years  previous  to  my  seeing  her.  This  diagnosis  was  made  by 
a  prominent  oculist  whom  she  consulted  about  the  projection  of  her  left 
eye.  She  has  been  treated  much  of  the  time  ineffectually  by  various 
physicians,  remaining  with  each  long  enough  only  to  experience  more  or 
less  benefit,  and  then  changing.  The  eyes  exhibit  clearly  the  peculiar 
appearance  of  patients  with  exophthalmic  goitre,  the  left  one  being  more 
strikingly  prominent,  and  being  of  but  little  service  fur  vision,  she  soon 
losing  control  of  it.  The  other  phenomena  of  the  disease  have  been  present 
for  some  years — irregularity  of  the  heart's  action,  and  at  times  severe 
palpitation,  and  enlargement  of  the  thyroid ;  but  this  is  not  so  very 
marked. 

"  Five  years  before  coming  to  me  she  experienced  a  severe  nervous 
shock,  and  dates  her  skin  trouble  from  that  period.  She  states  that  she 
has  not  perspired  since.  She  began  then  to  have  'a  fine  rash  and  redness 
all  over  the  body,'  and  itching.  This  continued  about  the  same,  ofi*  and 
on,  for  four  years,  when,  after  being  weak  and  exhausted,  and  having 
various  hysterical  difficulties,  the  itching  became  more  general,  and  an 
eruption  corresponding  to  that  now  existing  appeared.  Lumps  would 
foi-m  on  the  forehead  and  on  various  parts  of  the  body ;  sometimes  the 
face  and  head  would  appear  greatly  swollen. 

"  When  first  seen  she  was  in  a  pitiable  state  of  nervous  anxiety  ;  the 
itching  of  the  feet  and  toes  and  sometimes  of  other  parts  of  the  body  she 

^  Archives  Gen.,  June,  1875 ;  and  London  Me  1.  Record,  Sept.  15,  1875. 


EXOPHTHALMIC    GOITRE.  507 

described  as  agony.  At  the  first  visit  there  was  not  so  much  to  be  seen 
on  the  skin,  but  there  were  a  few  urticarial  blotches  on  various  parts  of 
the  body  and  limbs.  While  under  observation,  however,  she  had  several 
acute  attacks  of  skin  trouble,  all  of  the  same  sort.  On  one  occasion  she 
woke  with  the  upper  lip  greatly  swollen,  and  with  swellings  on  various 
parts  of  the  body.  On  the  following  day,  when  seen,  the  whole  face  was 
swollen  and  puffy ;  on  the  middle  of  the  forehead  there  was  a  large  erythe- 
matous lump,  also  one  beneath  the  right  eye,  and  smaller  ones  about  the 
face.  The  hands  were  swollen  ;  on  the  right  hand,  near  the  little  finger, 
there  was  an  erythematous  patch,  somewhat  swollen  and  with  two  small 
vesicles  on  it.  There  were  also  various  erythematous  and  urticarial 
blotches  about  both  hands  and  wrists ;  and  on  the  back  of  the  left  hand, 
near  the  thumb,  there  was  a  red  spot  with  the  skin  broken,  as  if  the  seat 
of  a  former  vesicle.  The  whole  surface  cf  the  skin  burned  as  if  scalded 
or  scratched  ;  there  was  no  pain  on  deep  pressure.  On  another  occasion, 
a  day  or  two  after  there  had  been,  according  to  her  statement,  numerous 
swellings  on  various  parts  of  the  body,  the  remains  of  several  were  visible 
on  the  right  cheek,  and  on  the  arms  there  were  numerous  stains,  some  of 
them  quite  dark,  as  if  the  parts  had  been  bruised — the  remains  of  the 
lumps ;  the  hands  and  arms  were  manifestly  swollen,  and  there  were 
urticarial  wheals  on  the  limbs  and  body." 

The  following  case  is  one  of  unilateral  thyroid  enlargement,  with  double 
exophthalmos : — 

Mrs.  L.  B.,  28,  U.  S.  ;  milliner.  Was  always  well  until  eight  years 
ago,  when  her  present  difficulty  began.  She  was  them  living  in  New 
York,  and  actively  employed.  At  this  time  she  noticed  the  growth  of  a 
goitre  upon  the  right  side  of  the  neck,  which  pulsated  violently  when  she 
was  excited  or  over-fatigued.  She  then  flushed  easily,  and  often  had 
headaches,  which  were  quite  intense.  These  she  has  now,  and  her  pain 
is  of  the  congestive  variety,  and  diffused.  She  presented  herself  at  the 
out-patient  department  of  the  New  York  Hospital,  complaining  of  a  pain 
just  beneath  the  border  of  the  last  rib  on  the  left  side,  which  was  quite 
constant,  but  not  increased  by  pressure,  or  by  taking  a  long  breath,  or  after 
eating.  The  pain  was  most  severe  in  the  morning,  and  seemed  to  move 
off  towards  night.  Her  heart  seemed  healthy,  so  far  as  valvular  lesions 
were  concerned,  for  no  abnormal  murmur  was  present ;  but  there  was 
great  rapidity  of  action,  the  pulse-beats  varying  from  106-120  per  minute. 
The  pulse  was  also  quite  bounding,  and  full.  The  carotids  pulsated  quite 
strongly,  and  there  was  a  very  marked  venous  thrill  perceptible  in  the 
jugulars.  Upon  the  right  side  of  the  neck,  just  above  the  sterno-clavicu- 
lar  articulation,  and  extending  laterally,  there  was  a  tumor  measuring 
2i  inches  in  length,  and  about  2  inches  in  breadth.  The  marked  pulsa- 
tion of  this  growth  led  Dr.  Slaughter  and  myself  to  suppose  at  first  that 
it  was  an  aneurism,  but  we  were  unable  to  reduce  it  by  pressure,  or  to 
diminish  its  size  by  compression  of  the  carotid  ;  and  there  was  no  history 
of  injury.  The  peculiar  movement  was  due  to  the  pulsation  of  the  carotid 
upon  which  it  rested  above,  and  laterally  passed  the  right  jugular  vein, 
which  was  also  agitated  by  the  transmitted  pulsation  of  the  carotid. 
When  the  hand  was  placed  upon  the  enlargement  there  was  perceived  an 
unduiatory  or  "purring"  movement.  No  bruit  was  heard  with  the  stetho- 
scope, but  the  tracheal  sound  was  readily  perceived.     This  growth  under- 


508  CEREBRO-SPINAL    DISEASES. 

went  variation  in  its  size.  Cold  weather  seemed  to  influence  it  in  this 
way,  and  stimulants,  or  other  ascciicies  which  increased  the  blood  pressure, 
materially  modified  its  size.  The  face  was  puffed,  bloated,  and  red,  and 
the  eyeballs  were  somewhat  prominent,  while  the  pupils  were  dilated,  and 
the  irides  rather  sluggish.  She  was  not  hypermetropic,  and  there  were  no 
other  defects  noticed.  By  steady  pressure  I  was  enabled  to  perceive  the 
"  cushion  feeling"  alluded  to  by  medical  writers  who  have  observed  this 
disease.  Her  companions  twitted  her  in  regard  to  her  fixed  stare,  which 
resulted  from  the  exophthalmos.  Her  ankles  and  feet  were  cedematous, 
and  pitted  deeply  on  pressure.  Her  urinary  organs  seemed  to  be  in  order, 
and  there  were  no  indications  of  renal  disease.  She  has  noticed  at  times 
patches  of  rusty  discoloration  which  appeared  about  her  neck  and  upon 
the  left  side  of  her  face.  These  lasted  for  several  days,  and  then  faded 
away.  She  has  had  several  minor  symptoms,  such  as  nose-bleed,  which 
occurs  even  now,  every  two  or  three  weeks.  Her  menses  are  scant,  but 
there  is  apparently  no  uterine  disease.  Her  digestion  is  feeble,  and  she  is 
slightly  constipated.  M- — Ext.  ergotte  fl.  5j,  t.  i.  d. 

Causes. — The  disease  is  one  of  adult  life,  and  there  are  about  twice 
as  many  females  as  males  affected.  But  few  cases  have  been  reported  in 
which  the  disease  appeared  before  puberty.  Devol  saw  a  case,  the  pa- 
tient being  a  girl  of  two  and  one-half  years.  It  is  connected,  in  some 
cases,  with  metrorrhagia,  or  hcemorrhoidal  bleeding,  or  in  others  with 
heart  disease;  but  though  many  authors  consider  anaemia  to  be  an  im- 
portant cause,  others  are  doubtful. 

Examples  of  traumatic  origin  have  been  noted  by  Begbie^  and  Von 
Graefe,^  and  others  have  been  apparently  of  idiopathic  origin.  The  case 
of  the  first  followed  injury  to  the  occiput. 

Morbid  Anatomy  and  Pathology. — The  observations  of  those 
who  have  made  autopsies,  differ  greatly.  Morel  Mackenzie  found  soften- 
ing of  the  corpora  quadrigemina  and  the  posterior  part  of  the  medulla. 
The  heart  was  not  much  affected,  there  being  only  slight  atheromatous 
deposits  on  the  mitral  and  aortic  valves,  with  thinness.  Other  observers 
have  found  hypertrophy  of  the  heart  and  insufficiency  of  its  valves,  but 
in  other  cases  there  were  no  heart  lesions  whatever.  The  thyroid  gland 
has  been  found  to  contain  enlarged  vessels,  and  the  orbits  an  increased 
quantity  of  fatty  tissue.  In  one  of  Begbie's  cases  there  was  sinking  of  the 
eyeballs  in  the  orbital  cavities  after  death. 

Much  discussion  has  taken  place  in  regard  to  the  pathology  of  the  af- 
fection, but  recent  investigations  point  to  the  nervous  origin  of  the  dis- 
ease. The  cervical  sympathetic  has  been  found  to  be  altered,  and  numer- 
ous instances  of  the  change  have  been  brought  forward  by  Recklinghausen,' 
Trousseau,*  Archibald,^  and  others.  In  eight  cases  of  exophthalmic  goitre, 
referred  to  by  Arnozan,®  there  was  degeneration  of  the  cervical  sympa- 

^  Edinburgh  Med.  Journal,  February,  1849. 

2  Arohiv.  fiir  Oplithal.,  1857. 

'  Deutsche  Klinik,  1863. 

*  Trousseau  and  Peter,  Gaz.  Hebdom.,  1864. 

5  Med.  Times  and  Gaz.,  1865.  «  Op.  cit. 


EXOPHTHALMIC    GOITRE.  509 

thetic  in  all;  but  in  four  other  cases  no  such  lesion  was  discoverable. 
In  ^Ebstein's  case,  as  well  as  those  of  ^ Keith  and  Knight/  the  sympa- 
thetic was  involved  alone,  and  more  often  on  both  sides.  Notwithstanding 
this  explanation  (the  sympathetic  origin),  others  contend  that  it  is  a  dis- 
ease of  the  brain ;  and  still  another  theory  is  accepted  by  those  who  con- 
sider it  a  cardiac  disease  per  se.  The  nervous  origin  seems  to  me  to  be 
that  which  is  most  acceptable.  Not  only  does  the  use  of  galvanic  treat- 
ment, which  cures  the  disease,  suggest  the  neurotic  character  of  the  affec- 
tion, but  the  hysterical  phenomena  mentioned  by  Basedow,  and  noticed 
frequently  by  others,  are  certainly  significant. 

^  We  may,  I  think,  consider  the  disease  to  be  dependent  upon  an  affec- 
tion of  both  the  sympathetic  and  spinal  accessory  nerves.  The  condition 
of  the  vessels  of  the  thyroid  gland  and  those  of  the  orbit,  the  flushing  of 
the  face,  and  general  disturbance  of  digestion,  are  probably  due  to  the  al- 
tered function  of  the  first-mentioned  nerve,  and  the  heart  excitement  is  a 
consequence  of  deficient  innervation  of  the  accessories. 

Diagnosis.— There  need  be  no  mistake  made  in  the  diagnosis  of  this 
affection  from  simple  goitre,  and  after  this  is  accomplished  there  is 
nothing  else  suggested.  An  inspection  of  the  enlarged  thyroid,  and 
the  protruding  eyeballs,  and  the  detection  of  the  vascular  excitement, 
are  sufficient  to  enable  us  to  say  that  the  case  is  one  of  exophthalmic 
goitre. 

Prognosis.— A  cure  is  recorded  by  Cheadle,*  another  by  Mackenzie, 
who  also  reported  a  death.  Bartholow*  has  cured  three  patients  ;  Dr.  J.' 
P.  Thomas,^  of  Kentucky  details  a  very  interesting  case  which  ended 
fatally  in  five  years.  Very  little  can  be  said  in  regard  to  the  character 
of  the  disease,  but  it  his  been  cured  in  certain  instances  in  a  year  or  two. 
It  may  last  for  several  years,  however,  and  is  essentially  a  chronic  affec- 
tion. Trousseau,  Charcot,  and  Corlieu*  report  cures,  in  which  pregnancy, 
uterine  hemorrhage,  or  some  such  complications  occurred  during  the  dis- 
ease, influencing  its  disappearance.  Of  course,  the  existence  of  organic 
cardiac  disease  gives  the  affection  a  very  serious  character. 

Treatment.— Galvanism,  it  seems,  has  succeeded  admirably,  and  Bar- 
tholow  has  cured  three  cases  by  this  agent.  'Eulenburg  treated  exoph- 
thalmic goitre,  as  early  as  1867,  very  successfully,  and  Meyer  and  Chvostek 
obtained  the  most  happy  results.  Eulenburg  recommends  very  mild  gal- 
vanic currents,  and  he  uses  from  6-8  elements.  I  have  used  the  current 
from  10-15  Leclanche  cells,  the  water  column  being  employed  to  regu- 
late the  same. 


^  Quoted  bj  Eulenburg. 

2  Medical  Times  and  Gazette,  Nov.  11,  1865. 

*  Boston  Med.  and    Surgical  Journal,  April  19,  1868. 

*  St.  George's  Hospital  Eeports,  vol.  iv.,  1869. 

*  Eichmond  and  Louisville  Med.  Journal,  1877. 
fi  Rep.  by  Jaccoud,  vol.  i.,  p.  672,  2d  edition. 

^  Cyclopaedia  of  Practical  Medicine,  vol.  xiv.,  p.  102,  Am.  trans, 


510  CEREBRO-SPINAL    DISEASES. 

Roth  '  reports  a  case  of  exophthalmic  goitre,  the  patient  being  a  woman 
fifty  years  of  age,  her  menopause  having  taken  place  six  years  before. 
She  became  debilitated,  suffered  from  palpitation  and  sweating  at  night, 
and  afterwards  there  was  gradual  enlargement  of  the  thyroid  gland  and 
protrusion  of  the  eyeballs.  The  pulse  was  120,  and  the  temperature 
normal.  It  was  impossible  for  her  to  close  her  eyelids.  The  exophthal- 
mos was  greater  on  the  left  side,  and  the  thyroid  was  more  enlarged  on 
the  opposite  side. 

Galvanism  was  used,  the  positive  pole  being  placed  on  the  upper  part 
of  the  sternum  and  the  negative  on  the  superior  cervical  ganglion.  On 
the  right  side  ten  cells  produced  no  sensation,  but  on  the  left,  six  were 
sufficient  to  produce  burning.  The  current  was  also  passed  through  the 
back.  The  night-sweats  and  palpitation  diminished,  and  she  grew  stronger. 
At  the  end  of  a  month  she  had  gained  two  pounds  in  weight,  but  the 
reduction  in  size  only  occurred  in  the  left  exophthalmos  and  left  portion 
of  the  thyroid. 

Chalybeate  preparations,  digitalis,  ergot,  and  cod-liver  oil  are  all  excel- 
lent remedies.  Since  the  appearance  of  the  first  edition  of  this  book  I 
have  cured  one  case  by  ergot,  and  greatly  helped  another  by  the  con- 
tinued administration  of  the  Syrup  of  hydroiodic  acid  in  doses  3i--^ss 
thrice  daily.  If  galvanism  be  used,  we  should  bring  the  sympathetic 
nerve  under  its  influence  by  placing  one  pole  (the  positive)  at  the  angle 
of  the  lower  jaw,  and  apply  the  negative  over  the  epigastrium  or  the 
thyroid. 

1  Wien.  Med.  Presse,  1875,  No.  30. 


NEURALGIA.  511 


CHAPTER    XVI. 

DISEASES  OF  THE  PERIPHERAL  NERVES. 
NEURALGIA. 

Synonyms. — (See  special  varieties.) 

Definition. — Neuralgia  may  be  defined  as  "  a  disease  of  the  nervous 
system,  manifesting  itself  by  pains  which  in  the  majority  of  cases  are 
unilateral,  and  which  appear  to  follow  accurately  the  course  of  particular 
nerves,  and  ramify  sometimes  into  a  few,  sometimes  into  all,  the  terminal 
branches  of  those  nerves."^ 

Neuralgia  is  essentially  the  result  of  lowered  vitality,  and  is  never  a 
consequence  of  any  sthenic  condition.  This  is  proved  by  the  circum- 
stances under  which  it  occurs ;  it  taking  its  origin  from  general  debility, 
rheumatism,  syphillis,  or  malaria,  or  some  other  disease  which  produces 
a  cachexia.  Anstie  very  justly  considers  that  it  is  the  first  expression  of 
a  condition  which  later  on  becomes  paralysis — one  being  a  partial  dis- 
turbance, or  cutting  off  of  the  nervous  supply ;  and  the  other  a  complete 
interruption  of  the  nervous  force;  and  it  is  a  familiar  fact  that  neuralgia 
very  often  precedes  loss  of  power  in  parts  supplied  by  an  affected  nerve. 

Neuralgia  is,  then,  a  disease  in  which  pain  is  the  prominent  symptom, 
and  with  which  circulatory,  trophic,  and  motorial  disturbances  may  be 
connected. 

Pain. — Neuralgic  pain  is  quite  distinct  from  that  of  any  other  disease. 
It  is  not  at  all  like  that  of  neuritis,  which  is  constant  and  aggravated  by 
pressure,  but  it  is  paroxysmal,  and  is  characterized  by  a  stage  of  increas- 
ing intensity  and  rapid  recurrence,  and  by  a  second  stage  of  "  wearing 
out "  or  subsidence.  It  appears  suddenly,  disappears,  and  returns,  being 
broken  by  a  period  of  rest.  These  breaks  or  intervals  of  remission 
become  shorter  as  the  attack  increases  in  severity,  until  the  pain  seem,s 
almost  continuous.  When  the  climax  is  reached,  the  intervals  grow  in 
length,  and  the  pain  diminishes  in  severity,  and  finally  subsides.  Re- 
peated neuralgic  attacks  leave  the  nerve  in  a  hypersesthetic  condition,  so 
that  at  particular  points  it  is  tender  and  sensitive  to  pressure. 

These  foci  of  exalted  sensation  have  been  called  by  Valleix^  "les  points 
douleureux,"  and  correspond  to  the  points  of  emergence  of  the  nerve 
from  its  foramen,  or  at  a  point  when  it  passes  from  a  deep  to  a  superficial 
course.  The  terminal  ends  of  nerves  are  much  more  often  the  seat  of  this 
tenderness  than  any  other  part.  The  external  ramifications  of  the  supra- 
orbital branch  of  the  fifth  or  the  small  filaments  of  other  nerves — the 

1  Anstie,  Neuralgia,  etc.,  p.  14.  -Traits  des  Nevralgies,  Paris,  1841. 


512  DISEASES    OF    THE    PERIPHERAL    NERVES. 

ulnar  aud  radial  for  instance — are  not  rarely  painful  to  pressure.  These 
painful  points  are  met  with  frequently  in  cases  of  facial  neuralgia.  A 
gentleman  who  consulted  me  some  time  ago  presented  this  indication  of 
facial  neuralgia,  there  being  several  hyperaesthetic  spots  in  the  roof  of  his 
mouth,  aud  his  gums  on  one  side  were  exquisitely  tender. 

Circulatory  dkturbancei,  of  a  quite  marked  character,  are  pronounced 
features  of  the  neuralgic  attack.  The  pulse  at  first  is  irritable,  small  and 
quite  rapid.  A  species  of  fluttering  palpitation  is  also  present,  and  the 
surface  is  pale  and  cool.  In  the  later  stages  of  the  attack,  after  the  pain 
has  grown  decided,  the  face  becomes  flushed ;  the  pulse  soft,  full,  and 
quite  bounding ;  and  the  eyes  may  be  suffused  and  bloodshot,  should  the 
attack  be  one  of  facial  neuralgia. 

During  this  stage,  and  after  the  subsidence  of  the  pain,  the  patient 
may  sweat  profusely. 

Trophic  Disturbances. — These  may  be  connected  with  the  acute  pa- 
roxsyms,  or  may  result  from  repeated  attacks.  Among  the  former  may  be 
pemphigus,  and  herpetic  and  bullous  eruptions;  and  among  the  latter,  loss 
of  teeth  or  hair,  or  alteration  in  the  coloring  matter  of  the  hair,  atrophy 
of  muscular  tissue,  and  various  cutaneous  changes.  Charcot  and  Weir 
Mitchell,  as  well  as  various  writers  upon  dermatology,  have  called  at- 
tention to  the  connection  of  aggravated  neuralgic  pain,  with  various 
cutaneous  diseases.  The  most  striking  of  these  neurotic  skin  diseases  is 
herpes  zoster,  in  which  eruptions  of  a  vesicular  character,  a  cluster 
of  patches  are  found  here  and  there  along  the  course  of  the  affected 
nerve.  The  pain  precedes  the  appearance  of  the  eruption,  and  may  con- 
tinue during  its  existence,  and  for  some  time  after,  or  there  may  remain 
a  pruritus,  limited  to  the  parts  which  have  been  the  seat  of  eruption. 
The  neurotic  character  of  this  complication  may  be  proved  by  its  very 
rapid  disappearance  after  galvanization  of  the  affected  nerves,  or  admin- 
istration of  large  doses  of  quinine.^  The  other  trophic  alterations,  which 
are  secondary,  will  be  considered  at  a  later  period. 

Motility. — Connected  with  some  forms  of  neuralgia  are  certain  condi- 
tions of  spasm.  In  form  of  facial  neuralgia  which  has  been  known 
as  tic  epileptiform  or  tic  douloureux,  tonic  spasm  of  the  eyelid  or  of  the 
masseter  muscles  is  present  as  a  decided  symptom.  Convulsive  move- 
ments of  the  legs,  due  to  spasms  of  the  flexors,  have  also  been  observed 
in  sciatica  by  Anstie;  but  in  cases  in  which  I  have  noticed  this  symptom, 
it  seemed  rather  a  result  of  excessive  pain,  and  an  effort  upon  the  part  of 
the  patient  to  relax  the  pressure  upon  the  affected  nerve.  Local  spasms 
are  quite  common ;  and  the  muscles  of  the  face,  of  the  trunk  or  limbs, 
and  the  vomiting  of  sick  headache,  are  varieties  of  spasmodic  action 
which  may  be  cited  as  examples  of  this  kind.  In  a  case  lately  under 
treatment,  I  have  been  reminded  of  a  condition  which  I  have  several 
times  observed — a  species  of  heart  pain  resembling  that  of  angina  pec- 

'  A  form  of  skin  disease  lately  denominated  pompholyx  by  Dr.  A.  R.  Robinson,  of 
New  York,  is  an  example  of  a  neurosLs  of  this  kind. 


NEURALGIA.  518 

toris,  and  connected  with  facial  neuralgia.  With  this  pain  there  would 
be  spasmodic  contraction  of  the  muscles  of  the  thorax.  Mitchell  ^  "  has 
encountered  from  time  to  time  certain  forms  of  neuralgia,  accompanied 
by  muscular  spasms  and  extravasations  of  blood  in  the  affected  part.  He 
relates  three  cases,  all  occurring  in  females,  and  explains  the  circum- 
scribed hemorrhages  by  nutritive  changes  in  the  walls  of  the  vessels, 
occasioned  by  conditions  of  the  nervous  system  analogous  to  atrophic 
changes  in  the  skin  and  nails  in  nervous  diseases." 

Valleix  has  divided  the  neuralgias  into  the  superficial  and  the  visceral, 
and  classifies  them  as  follows : — 

A.  Superficial. 

1.  Neuralgia  of  the  fifth  nerve  (trifacial  or  trigeminal  neuralgia ) 

2.  Cervico-occipital. 

3.  Cervico-brachial. 

4.  Intercostal. 

5.  Lumbo-abdominaL 

6.  Crural. 

7.  Sciatica. 

B.   Visceral, 

1.  Uterine  or  ovarian  neuralgia. 

2.  Neuralgia  of  the  urethra. 

3.  "  "      bladder. 

4.  "  "       rectum, 

5.  "  "       testis. 

6.  Hepatic  neuralgia. 

7.  Neuralgia  of  the  heart. 

8.  "  "       stomach. 

9.  Laryngeal  and  pharyngeal  neuralgia. 

Among  the  first  group  the  most  important  is  neuralgia  of  the  fifth  nerve, 
which  may  also  exist  with  a  motor  complication,  as  tic  epileptiform,  or  with 
gastric  complications,  as  migraine  or  "  sick  headache." 

FACIAL  NEURALGIA. 

Synonyms. — Face-ache ;  Fothergill's  face-ache  ;  Prosopalgia ;  Tri- 
geminal neuralgia ;  Tic  douloureux ;  Migraine  y  Sick  headache. 

The  supra-orbital  branch  may  be  alone  afiected,  and  the  pain  confined 
to  the  brow  and  top  of  the  head,  or  it  may  be  quite  generally  difinsed  over 
the  face  and  head,  the  three  branches  being  involved.  The  first  division 
of  the  nerves  is,  however,  the  most  common  seat  of  neuralgia ;  but  it  i& 
not  unusual  for  an  attack  to  begin  above,  and  finally  extend  to  all  of  the- 
divisions  of  the  nerve  on  one  side. 

Migraine,  or  "  sick  headache,"  presents  the  following  features :  The  at- 
tack may  be  preceded  by  some  chilliness,  pallor,  and  uneasiness,  and  is 


^  American  Joura.  of  Med.  Sci.  Iviii.  Id. 

33 


514  DISEASES    OF    THE    PERIPHERAL    NERVES. 

ushered  in  by  a  twiuge  of  pain,  which  begins  just  above  the  eye  on  one 
side,  and  radiates  over  the  head.  The  pain  is  often  erroneously  referred 
by  the  patient  to  both  sides  of  the  head,  when,  in  reality,  but  one-half  is 
affected.  Deep-seated  orbital  pain,  photophobia,  hemiopia  and  nausea, 
with  an  irritable,  thready  pulse,  and  increase  of  pain,  immediately  usher 
in  the  attack,  which  rapidly  increases  in  severity  ;  the  pulse  after  a  while 
losing  its  asthenic  character,  and  becoming  full  and  bounding.  The  pa- 
tient's face  becomes  flushed,  and  his  skin  red  and  sweaty,  and  in  rare 
cases  the  sweating  is  confined  to  one  side  of  the  face.  The  paroxysms  of 
pain,  which  at  first  were  separated  by  intervals  of  relief,  next  become  al- 
most continuous,  but  after  a  time,  during  which  the  patient  may  feel  like 
vomiting,  they  become  less  severe,  and  finally,  after  his  stomach  has  been 
emptied,  may  disappear  altogether.  The  features  of  an  attack  of  this  kind 
are  too  familiar  to  need  elaboration.  The  following  case  will  serve  as  an 
illustration: — 

Mrs.  Gr.  is  a  delicate,  hysterical  woman,  who  devotes  most  of  her  time 
to  duties  of  society.  Her  domestic  affairs  are  Avorrying,  and  the  constant 
excitement  of  entertaining,  late  hours,  and  the  management  of  several 
unruly  children,  have  so  worn  upon  her  that  now,  at  the  end  of  the  winter, 
she  is  ansemic,  "  run  down,"  and  suffers  from  want  of  appetite,  insomnia, 
and  general  debility.  About  twice  a  week,  at  irregular  times,  she  suffers 
in  the  beginning  from  light  pains,  radiating  from  the  right  eye,  and  over 
the  head,  which  become  quite  severe,  and  increase  during  the  next  hour 
or  two.  She  usually  becomes  cold,  and  bundles  herself  up  in  shawls  and 
wraps.  Her  eyelids  feel  heavy,  and  the  "  skin  covering  "  her  "  face  feels 
as  if  it  were  drawn  tightly."  She  is  nervous  and  irritable,  and  cannot 
bear  the  presence  of  her  children,  and  is  sometimes  so  depressed  that  she 
bursts  into  tears.  She  has  a  vague  dread  of  some  trouble,  the  character 
of  which  she  does  not  know.  The  pain  increases  in  severity,  and  becomes 
almost  unbearable.  Her  eyes  are  hot,  and  "  it  seems  as  if  a  peg  was  be- 
ing driven  in  from  behind."  Her  face  becomes  very  hot,  and  her  tem- 
poral vessels  throb.  The  slightest  step  she  may  take  in  walking  so  jars 
her  head  that  it  gives  rise  to  intense  pain.  She  "  feels  as  if"  her  "  heail 
would  split  open."  She  cannot  look  out  of  the  window,  but  lies  upon  ht  r 
bed,  and  buries  her  face  in  the  pillows.  Nothing  seems  to  relieve  her. 
She  may  lie  so  for  hours,  panting  for  breath,  and  pressing  her  aching  heaJ. 
After  a  variable  time,  sometimes  two  hours,  sometimes  a  day,  the  pain  is 
diminished  somewhat,  and  she  becomes  nauseated ;  not  because  food  lies 
undigested,  for  she  has  taken  none  for  some  time,  but  the  vomiting  is  of 
a  purely  cerebral  character.  She  attempts  to  vomit,  but  cannot  bring  up 
anything.  The  effort  at  retching  jars  her  body,  and  increases  the  pain 
After  this  state  of  affairs  has  lasted  for  some  little  time,  she  becomes  ex- 
hausted, and  falls  back  upon  the  bed,  sweating  profusely.  The  pain  grow 
very  much  less  severe,  is  dull  and  throbbing,  and  finally  she  sinks  into  ; 
deep  sleep,  from  which  she  awakens  somewhat  relieved. 

The  variations  in  pain  and  circumstances  which  give  rise  to  the  disease 
have  led  different  observers  to  apply  such  names  as  "  rheumatic,"  "  hys 
terical,"  "  sympathetic,"  "  organic,"  "syphilitic,"  and  "  clavus."  Thest 
terms  have  little  value,  and  it  seems  that  a  nomenclature  based  upon  th( 


NEURALGIA.  515 

anatomical  situation  of  the  neuralgia  is  all  that  is  needed,  and  it  certainly 
would  do  away  with  much  confusion.  Facial  neuralgia,  unless  it  be  due 
to  temporary  exciting  causes  which  may  be  readily  removed,  is  rather  an 
obstinate  affection.  It  may  take  a  periodic  character,  especially  if  it  be 
connected  with  malaria  ;  or  it  may  be  more  intense  at  night,  should  it  be 
of  syphilitic  origin.  The  true  attack  rarely  lasts  beyond  a  few  hours,  but 
attacks. (especially  of  tic-douloureux)  may  be  so  frequent  as  to  become 
almost  continuous.  The  tendency  is,  I  think,  for  the  disease  to  become 
firmly  rooted,  and  to  increase  in  severity.  If  there  be  a  rheumatic,  mala- 
rial, or  ansemic  form,  there  is  no  reason  why  the  disease  should  not  subside 
when  these  morbid  conditions  are  removed.  As  to  clavus,  in  which  the 
pain  is  compared  to  that  which  would  probably  follow  the  driving  of  nails 
through  the  skull,  it  may  be  said  that  this  is  an  hysterical  condition,  and 
the  patients'  descriptions  are  based  upon  the  workings  of  a  disordered 
imagination. 

There'  are  very  few  cases  of  facial  neuralgia  in  which  all  the  branches 
may  not  be  involved  at  some  time  or  other.  If  the  neuralgia  be  confined 
more  particularly  to  the  first  and  second  branches  of  the  fifth,  the  temples 
and  forehead,  upper  eyelid,  root  of  the  nose,  and  the  orbits  will  be  the 
points  at  which  the  pain  will  be  the  most  severe.  Toothache,  above  and 
below,  will  indicate  involvement  of  the  middle  and  lower  branches,  and  if 
the  lingualis  be  affected,  which  it  quite  rarely  is,  the  tongue  will  be  the 
seat  of  the  violent  pain.  The  painful  pointy  are  to  be  found  principally 
over  the  supra-orbital  notch,  the  infra-orbital  foramen,  the  "  malar  point,'' 
or  in  the  roof  of  the  mouth,  over  the  mental  foramen,  and  in  front  of  the 
ear.  During  the  attack  it  is  not  uncommon  to  find  hypersecretion  of  sa- 
liva, that  fluid  passing  from  the  angle  of  the  mouth  in  great  quantity,  and 
when  the  supra-orbital  and  infra-orbital  branches  are  involved  there  may 
be  a  corresponding  profuse  lachrymation.^  Erb  ^  has  called  attention  to 
the  occasional  increase  of  secretion  from  the  nasal  mucous  membrane. 
This  has  been  referred  by  Vulpian  to  irritation  of  one  of  the  spheno- 
palatine ganglia.  The  patient  is  nearly  always  excited  and  irritable,  and 
if  the  paroxysms  be  of  frequent  occurrence  he  suffers  from  insomnia,  and 
is  entirely  unfitted  for  his  daily  occupations.  It  must  not  be  supposed 
that  the  vomiting  of  migraine  has  any  direct  connection  with  the  condi- 
tion of  digestion.  The  attacks  are,  however,  aggravated  by  the  presence 
of  undigested  food  in  the  stomach. 

The  deep  neuralgias  of  this  nerve  are  very  obstinate,  and  often  beyond 
the  reach  of  any  treatment.  This  is  notably  the  case  when  the  superior 
maxillary  or  its  orbital  branches  are  affected.  The  ocular  symptoms  are 
then  of  the  most  formidable  description,  and  life  to  the  patient  is  a  burden 
indeed. 

The  following  is  one  of  the  most  inveterate  cases  of  neuralgia  of  this 
kind  I  have  ever  observed.     The  patient's  trouble  began  in  1863,  while 


1  Sometimes  there  is  spasmodic  closure  of  the  orifice  of  the  lachrymal  duct. 
^  Ziemssen's  Cyclopaedia,  vol.  ii. 


516  DISEASES    OF    THE    PERIPHERAL    NERVES. 

at  school,  and  then  affected  the  superior  maxillary  and  infra-orbital 
branches  of  the  fifth  nerve.  His  sufferings  were  intense,  and  after 
trying  almost  all  forms  of  treatment,  and  consulting  medical  men  in 
Europe  and  in  this  country,  he  consented  to  subject  himself  to  an  opera- 
tion for  exsection.  The  history  he  brings,  which  was  taken  by  the  house 
surgeon.  Dr.  Peale,  of  Chicago,  details  the  surgical  procedures  under- 
taken. 

"  Patient  has  for  a  long  time  suffered  from  neuralgia  of  supra-  and 
infra-orbital  nerves,  and  the  superior  trochlear  nerve.  Prior  to  this 
he  had  a  closure  of  the  lachrymal  ducts  of  both  sides.  He  had  been  in 
Central  America,  where  he  was  exposed  to  severe  forms  of  malaria. 
About  two  years  ago,  Dr.  Strawbridge,  of  Philadelphia,  cut  off  the  supra- 
orbital nerves  at  their  point  of  exit  from  the  supra-orbital  foramen.  In 
either  eye  there  is  loss  of  accommodation,  and  a  high  degree  of  hyper- 
metropia.  Prof  Holme.?,  of  this  city,  atter  an  ophthalmoscopic  examina- 
tion, told  him  that  the  veins  of  the  retina  were  diminished  in  size. 

He  still  suffers  intensely  with  the  infra-orbital  nerves,  and  comes  in  de- 
siring to  have  them  excised.  He  receives  3?  grs.  morphia,  hypodermi- 
cally,  each  day. 

Dec.  18,  1876.  An  incision  made  downward  from  the  location  of  each 
infra-orbital  foramen  to  the  length  of  one  inch  through  the  tissues  of  the 
cheek,  the  nerves  raised  on  a  blunt  hook,  stretched  well  out,  and  chipped 
off  at  their  point  of  exit.  Ether  used  as  the  amesthetic,  collodion  and 
silk  sutures  to  approximate  the  edges  of  the  incision. 

I'^th.  Patient  suffering  from  intense  pain  referred  to  outer  edge  of  right 
lower  eyelid. 

23(/.  Considerable  cellular  inflammation  of  right  side  of  neck  and 
face. 

2%th.  Considerable  discharge  of  pus  from  incision  on  right  side  of 
face ;  swelling  very  much  diminished. 

29<A.  Discharge  of  pus  from  both  incisions  has  now  about  ceased  ;  con- 
siderable cellular  inflammation  of  right  side  of  face  in  parotid  region. 
He  claims  he  has  stiU  the  neuralgic  pain,  but  deeper  in  the  infra-orbital 
region. 

31s^  Considerable  swelling  and  a  great  deal  of  tenderness  on  either 
side  of  the  neck  below  the  jaw.     Patient  cannot  move  the  jaw. 

Jan.  5,  1877.  Face  continues  swollen,  and  very  painful ;  thinks  he 
still  has  the  old  neuralgic  pain  on  right  side.  Quantity  of  opiates  in 
twenty-four  hours  considerably  diminished. 

29</«.  Patient  again  placed  under  the  influence  of  ether.  An  incision 
made  on  the  right  side  in  the  site  of  the  old  one,  and  the  nerve  raised  on 
a  blunt  hook  and  divided.  Following  the  operation  the  pain  became 
severe,  and  the  hemorrhage  excessive.  For  a  couple  of  hours  all  sorts  of 
efforts  were  made  to  stop  it,  and  finally  we  were  obliged  to  resort  to  ol. 
terebinth,  and  ferri  persulph.  These,  with  compresses  bound  on  as  best 
we  could,  checked  it  so  that  it  only  oozed.  A  large  quantity  of  anodyne 
was  required  to  allay  pain. 

ZOth.  There  has  been  no  further  hemorrhage.     Morph.  pro  re  nata. 

Feb.  2.  All  dressing  removed  without  hemorrhage;  wound  left  open 
and  suppurating ;  dressed  with  carbolic  acid ;  pain  controlled  with 
morph. 


NEURALGIA.  517 

4th.  Complains  of  pain  in  rigbit  temple.  P.  M.  Severe  headache  ; 
wound  dressed  twice  a  day. 

11th.  Patient  had  been  doing  well  until  yesterday.  There  was  a  hem- 
orrhage from  the  wound  in  the  morning,  controlled  by  syringing  with 
cold  water.  Last  night  another  very  severe  hemorrhage  ;  used  dry  ferri 
persulph.  Has  had  three  hypodermic  injections  of  tgr,  morph.  each, 
daily.     Ordered  iodoform  to  be  sprinkled  in  wound. 

March  27.  At  3  P.  M.  patient  was  etherizecl,  and  Prof  Bogue  pro- 
ceeded to  resect  the  orbital  branch  of  the  superior  maxillary  nerve.  A 
circular  flap  begun  in  the  old  cicatrix  on  the  right  side,  and  curving 
backwards,  laid  bare  the  malar  bone.  An  opening  was  then  made  through 
its  quadrilateral  surface  with  a  trephine  into  the  antrum ;  the  floor  of  the 
orbit  was  then  gouged  away  and  the  nerve  hooked  up  and  ruptured. 
There  was,  following  this,  hemorrhage.  A  plug  of  sponge  was  then 
stuffed  into  the  antrum  and  left.  In  the  evening  there  was  a  severe 
hemorrhage  from  the  nostrils  and  mouth  ;  the  nostrils  were  plugged. 
Later  in  the  evening  the  sponge  and  plug  were  removed ;  the  antrum 
washed  out ;  there  was  a  brisk  hemorrhage.  Monsel's  styptic  was  freely 
injected ;  finally  the  antrum  was  again  plugged  with  sponge  soaked  in  the 
same  solution.  The  eyeball  was  noticed  to  project  considerably  more 
than  its  fellow,  but  the  sight  was  not  much  impaired.  Patient  has  had, 
till_  the  present  time  (10  A.  M.),  morph.  gr.  iij,  by  hypodermic  injection. 
This  morning  complains  of  great  pain  in  the  eye  and  upper  jaw.  Plugs 
not  removed.  Ordered  whiskey  and  morph.  to  allay  pain.  P.  M.  Pulse, 
76 ;  temp.  103°. 

'SOth,  A.M.  Pulse,  72;  temp.  100°. 

Yesterday  evening  the  sponge  plugs  removed  from  the  wound  ;  no 
hemorrhage  occurred  ;  they  were  not  replaced  ;  water-dressing  continued 
through  the  night.  This  morning  the  wound  is  suppurating  slightly  ; 
face  not  swollen  quite  so  badly.  Patient  has  had  one  grain  morph.  by 
hypodermic  injection  every  4  hours  for  the  past  48  hours.  Water-dress- 
ing continued.  Patient  still  complains  of  great  pain  in  the  right  eye  ; 
swelling  is  considerable;  eye  closed,  with  conjunctiva  protruding  from 
between  the  lids.  A  pledget  of  lint  saturated  with  alcohol  was  laid  in 
wound,  and  water-dressing  continued. 

April  1.  Is  feeling  better  ;  wound  is  suppurating  considerably  ;  is  not 
swollen  so  badly ;  plugged  with  lint  saturated  with  alcohol,  and  the  cold 
compresses  continued. 

del.  The  surface  of  the  wound  is  covered  with  healthy  granulations.  • 
The  eye  very  much  improved ;  can  open  it ;  can  distinguish  objects  at 
some  distance. 

Mh.  The  patient's  condition  rapidly  improved. 

6th.  Cavity  granulating  finely ;  appetite  good ;  everything  appears  fa- 
vorable at  this  time." 

The  patient  cam3  to  New  York  and  consulted  me  October  17,  1877. 
In  spite  of  a;ll  the  surgical  operations  the  pain  is  as  severe  as  it  ever  was, 
the  focus  of  intensity  being  evidently  the  orbital  branch.  The  eye  is 
without  sight,  but  no  retinal  changes  can  be  discovered,  except  paleness 
at  the  fundus.  The  conjunctiva  is  injected,  and  the  eye  is  suffused.  I 
gave  him  two  hypodermic  injections  of  morphia,  of  one  grain  each,  within 
an  hour,  but  none  of  the  physiological  effects  followed,  and  the  pain  re- 


518  DISEASES    OF    THE    PERIPHERAL    NERVES. 

inained  unabated.  Nothing  remains  to  be  done  but  deep  section  of  the 
nerve. 

A  formidable  neuralgia  is  that  connected  with  spasm  of  the  facial  mus- 
cles, which  has  received  the  name  of  tic  douloureux  or  tic  epileptiform.  The 
former  term  is  that  apjilied  by  Benedikt,  and  has  been  generally  accepted 
by  most  writers  to  express  the  violent  and  sudden  twinges  of  pain  which 
are  accompanied  by  very  forcible  spasms  of  the  facial  muscles.  These 
spasms  may  be  of  varying  degrees  of  severity.  The  eye  may  be  tightly 
closed  during  the  pairoxysm,  or  the  face  violently  drawn  to  one  side. 
The  attacks  are  generally  supposed  to  be  confined  to  those  individuals 
in  whom  there  is  a  neurotic  predisposition  ;  and  Erb,  Eulenburg,  and 
others  consider  tic  douloureux  to  be  a  disease  of  central  origin,  which 
seems  very  probable  for  some  reasons,  but  not  so  much  so  when  we  take 
into  account  the  fact  that  in  some  cases  the  disease  may  appear  and  dis- 
appear, there  being  occasionally  a  long  period  of  quiescence,  and  then  a 
relapse.  Anstie  considers  that  the  spasm  is  not  directly  connected  with  the 
pain,  but  is  rather  inclined  to  look  upon  it  as  a  coincidence,  or  as  a  result 
of  the  epileptic  tendency,  the  pain  and  epileptiform  spasm  being  separate 
expressions. 

A  very  interesting  case,  to  which  I  have  already  casually  alluded,  was 
sent  me  by  my  friend  Dr.  Sayre,  of  New  York. 

Mr.  K.  had  for  ten  or  twelve  years  suffered  from  neuralgia  of  the  fifth 
nerve  of  the  right  side.  His  habits  had  been  very  good,  and  there  was 
no  history  of  syphilis,  nor  any  evidence  that  it  had  existed.  About  ten 
years  ago,  after  exposure,  he  first  noticed  the  commencement  of  his  trou- 
ble, and  at  this  time  there  was  no  facial  spasm  or  very  decided  pain  ;  his 
attacks,  however,  which,  during  the  first  two  or  three  years,  occurred  at 
intervals  of  two  or  three  months,  became  much  more  frequent,  and,  within 
three  years,  have  become  almost  continuous,  so  that  there  is  rarely  an  in- 
terval of  five  or  ten  minutes  between  each  paroxysm.  Sleep  is  utterly  im- 
possible, and  he  has  been  obliged  to  resort  to  an  immense  quantity  of 
stimulants  for  the  purpose  of  procuring  rest. 

He  tells  me  that  very  often  he  drinks  a  pint  of  whiskey  before  retiring. 
During  his  visit  he  had  several  attacks  of  tic,  during  which  his  face  was 
drawn  up  and  agitated  by  clonic  spasm  of  the  muscles  of  the  right  side  ; 
these  attacks  lasted  one  or  two  minutes,  during  which  his  face  became 
flushed,  his  eyes  injected,  and  from  the  corner  of  his  mouth  trickled  a 
quantity  of  saliva;  the  gum  was  very  tender,  and  painful  points  before 
alluded  to  were  found  to  be  very  sensitive.  Numerous  painful  points 
were  also  found  upon  the  scalp,  over  the  supra-orbital  notch,  and  at  dif- 
ferent points  over  the  temporal  bone.  Before  I  saw  Mm  he  had  been 
under  several  varieties  of  treatment,  but  none  afforded  him  the  least 
relief. 

CERVICO-OCCIPITAL    NEURALGIA. 

When  the  posterior  branches  of  the  upper  cervical  nerves  are  the  seat 
of  neuralgia,  the  patient  will  complain  of  pains  beneath  the  occijiut,  be- 
hind the  ear,  and  sometimes  at  the  under  part  of  the  lower  jaw.  The 
pain  at  the  base  of  the  occiput  is  most  severe;  but  when  the  neuralgia  in- 


NEURALGIA,  519 

volves  the  anterior  nerve  branches,  and  pain  appears  behind  the  ear  and 
over  the  lower  part  of  the  face,  this  affection  may  be  mistaken  for  neural- 
gia of  the  fifth  pair.  The  pain  is  often  insupportable,  and  is  of  a  parox- 
ysmal character.  It  is,  on  the  other  hand,  of  a  localized  form,  and  so 
constant  in  some  cases  that  the  medical  man  may  be  led  to  suspect  in- 
flammatory conditions  of  other  parts.  During  the  active  pain  the  pa- 
tient may  be  unable  to  turn  his  head  or  open  his  mouth,  and  any  muscular 
movement  is  attended  with  distress.  The  skin  may  be  either  hypersesthe- 
tic  or  an£esthetic,  but  more  often  the  former,  and  I  have  had  patients  who 
■were  unable  to  bear  even  the  pressure  of  a  collar  or  other  neck  gear. 
The  skin  feels  to  the  patient  as  if  it  were  tightly  drawn  over  the  tissues 
beneath,  and  it  sometimes  may  be  red  and  appear  swollen.  The  hyperses- 
thesia,  when  it  involves  the  scalp,  is  so  distressing  that  the  patient  is 
unable  to  place  his  head  upon  the  pillow,  or  wear  a  hat  unless  it  is 
much  too  large  for  him  ;  and  heat  seems  to  increase  the  discomfort  to  a 
marked  degree.  The  post-cervical  muscles  may  be  the  seat  of  cramps, 
during  which  the  patient's  head  is  drawn  backwards  or  laterally  down- 
wards. Painful  points  may  be  found  in  two  or  three  situations,  but  most 
frequently  where  the  great  occipital  nerve  emerges.  The  spinous  pro- 
cesses of  the  upper  cervical  vertebrae  are  often  the  seats  of  painful  spots, 
and  it  is  not  rare  to  find  that  distress  is  caused  by  pressure  at  different 
places  over  the  occipital  bone. 

CERVICO-BRACHIAL   NEURALGIA. 

A  form  of  attack  manifesting  itself  in  severe  pains,  which  shoot  down 
the  arms,  hands,  and  back  of  the  neck.  Exquisite  cutaneous  hyperges- 
thesia  is  by  no  means  a  rare  accompaniment,  the  skin  being  so  tender  to 
pressure  that  the  slightest  touch  of  the  clothing  will  produce  intense  suf- 
fering. The  distribution  of  pain  corresponds  to  the  parts  supplied  by  the 
lower  cervical  nerves  or  regions  which  are  innervated  by  sensory  branches 
of  the  brachial  plexus. 

Erb^  has  given  a  diagram  which  demonstrates  the  districts  of  pain,  and 
their  source  of  supply,  which  may  be  made  use  of  in  tracing  the  course 
of  the  affected  nerves,     (See  page  534.) 

My  attention  has  been  directed  by  Dr.  Burral  to  a  condition  of  neu- 
ralgia which  is  often  mistaken  for  the  so-called  muscular  rheumatism,  and 
is  probably  due  to  an  involvement  of  the  circumflex  as  well  as  the  pos- 
terior thoracic.  The  pain  is  not  nearly  so  acute  as  that  of  some  of  the 
other  neuralgias ;  for  example,  the  facial  variety.  It  is  dull  and  terebrat- 
ing,  and  resembles  the  agonizing  though  temporary  pain  which  follows  a 
blow  upon  the  popularly  called  "  funny-bone,"  or  ulnar  nerve,  in  its  ex- 
posed position  at  the  internal  condyle.  The  pain  travels  down  into  the 
hand,  and  may  be  attended  by  a  spasm  of  the  muscles.  There  are  points 
of  tenderness  which  are  extremely  numerous.  Pressure  made  over  the 
supraclavicular  space,  just  below  the  lower  angle  of  the  scapula,  at  the 

1  Ziemssen's  Cyclopaedia,  vol.  xi.  p.  146, 


520  DISEASES    OF    THE    PERIPHERAL    NERVES. 

exposed  portion  of  the  ulnar  nerve  at  the  elbow,  and  at  •  the  points  of 
emergence  of  the  superficial  nerves  of  the  arm  and  forearm  as  they  pierce 
through  the  fascia,  gives  rise  to  pain.  Occasionally  there  are  tender 
spots  over  the  cervical  vertebrae.  The  skin  of  the  arm  is  often  cold,  and 
areas  of  capillary  emptiness  are  to  be  observed  either  during  an  accession 
of  pain  or  between  the  attacks.  In  rare  instances  it  is  not  unusual  for 
trophic  alterations  to  be  manifested.  In  a  patient  under  observation  the 
right  hand  is  reduced  in  size,  the  skin  is  dry,  puckered  and  livid ;  the 
lines  of  flexure  of  the  fingers  and  hand  are  red,  and  much  deeper  than 
upon  the  other  side  of  the  body  ;  and  the  nails  are  creuated  and  irregu- 
lar. Erb  alludes  to  an  excessive  sweating  of  the  fingers.  This  form  of 
neuralgia  is  decidedly  inveterate,  and  when  well  established  is  attended 
by  nocturnal  exacerbations.  The  use  of  the  affected  hand  is  sure  to  ag- 
gravate or  precipate  an  attack,  and  changed  of  temperature  act  usually 
in  the  same  manner. 

A  gentleman  sent  to  me  by  Dr.  Ives,  of  New  York,  had  suffered  in- 
tensely for  a  number  of  years,  and  his  pain  had  become  almost  constant. 
When  he  neglected  to  cover  his  arm  with  cotton  batting,  but  permitted 
his  coat  sleeve  to  come  in  contact  with  the  skin,  he  would  be  in  utter 
misery,  so  that  he  was  obliged  to  cover  it  with  some  soft  substance.  He 
was  very  cautious  in  selecting  a  position  at  night,  as  the  arm,  if  unsup- 
ported, dragged  the  muscles  of  the  shoulder  sufficiently  to  produce  a 
paroxysm. 

INTERCOSTAL   NEURALGIA,    OR   PLEURODYNIA. 

This  is  often  mistaken  for  pleuritis.  It  is  characterized  by  a  pain  which 
encircles  the  body,  and  may  be  referred  by  the  patient  to  the  region 
bounded  by  the  crest  of  the  ilium  below,  and  the  thorax  above  ;  but  it 
more  commonly  affects  the  lower  intercostal  nerves.  The  pain  is  always 
one-sided,  and  is  dull  and  continued,  but  may  sometimes  be  sharp  and 
paroxysmal,  radiating  from  the  spine  anteriorly.  The  skin  is  hyperses- 
thetic,  and  this  is  particularly  the  case  if  the  neuralgia  be  attended  by 
herpetic  patches.  The  painful  points  are  chiefly  over  the  inter-vertebral 
foramen,  and  where  the  nerve  pierces  the  muscles  anteriorly.  The  rectus 
muscles  contain  painful  spots  at  the  points  where  the  lower  intercostal 
nerves  pierce  the  investing  sheaths.  The  patient  during  the  paroxysm 
inclines  his  body  to  the  aflTected  side,  as  it  were  to  relax  the  muscular 
strain ;  he  perspires  freely,  and  his  face  wears  a  scared  and  anxious  ex- 
pression, suggestive  c^f  great  suffering.  His  breathing  is  "  catching  "  and 
shallow,  and  attended  by  the  least  possible  movement  of  the  thoracic 
walls  or  diaphragm. 

SCIATICA. 

Sciatica  is  perhaps,  next  to  facial  neuralgia,  one  of  the  most  trouble- 
some and  familiar  neuralgias.  It  rarely  begins  suddenly,  but  has  a 
gradual  onset,  attended  by  a  variety  of  disagreeable  and  annoying  symp- 
toms.    Cutaneous  hypersesthesia,  slight  fatigue  after  walking,  and  "  sore- 


NEURALGIA.  521 

ness,"  a  sensation  of  dragging  or  of  heaviness  of  tlie  leg  and  foot,  and  a 
number  of  minor  symptoms  of  a  vague  character  precede  the  actual  pain. 
This  is  exceedingly  severe,  and  may  exist  in  a  dull  form,  and  during  its 
continuance  there  may  be  paroxysms  consisting  of  twinges  or  "  darts  " 
shooting  down  the  back  of  the  leg.  Should  the  patient,  while  sitting, 
place  his  thigh  so  that  the  nerve  shall  be  pressed  against  the  edge  of  the 
chair,  the  paroxysm  may  be  precipitated.  Anstie  has  divided  sciatica 
into  three  varieties,  one  of  which  occurs  during  comparatively  early  life, 
and  is  connected  with  hysteria.  It  is  dependent  generally  upon  over- 
fatigue, and  affects  anaemic  people.  It  is  the  form  which  attends  in-egu- 
lar  menstruation,  and  the  pain  is  quite  severe.  In  this  variety  I  have 
rarely  found  any  painful  points. 

Before  the  fourteenth  year  neuralgia  of  the  sciatic  variety  is  very  un- 
common. In  124  cases  collected  by  Valleix,  none  were  under  seventeen 
years  of  age. 

Sciatica  of  the  second  variety  is  a  disease  of  adult  life,  and  is  a  result 
either  of  exposure,  or  some  such  cause  as  continued  pressure  of  the  nerve 
through  sitting  in  an  uncomfortable  position.  It  is  not  rare  among  busi- 
ness men,  or  clerks  who  sit  upon  high  wooden  chairs  or  stools,  and  who 
generally  do  not  support  their  legs  by  placing  the  feet  upon  ths  floor  or 
the  rounds  of  the  chair.  Anstie  connected  this  "middle-aged  sciatica" 
with  premature  decline,  and  states  that  the  patients  have  rigid  arteries, 
gray  hair,  and  the  arcus  senilis;  but  I  do  not  consider  that  these  indications 
of  decay  have  any  very  decided  bearing  upon  the  sciatica,  especially  in  the 
form  last  mentioned.  It  strikes  me  rather  that  the  causes  which  produce 
the  disease,  with  the  exception  of  dissipation  and  perhaps  syphilis,  gout, 
or  like  affections,  would  be  local.  Some  of  the  most  intractable  cases 
of  sciatica  I  have  ever  seen  were  persons  who  were  apparently  in  good 
general  health.  The  presence  of  "  painful  points  "  is  highly  characteristic 
of  this  form.  Foci  of  tender  nerves  may  be  found  corresponding  with 
the  emergence  of  the  sciatic  nerves  from  the  pelvis  ;  and  also  at  various 
points  corresponding  to  the  cutaneous  distribution  of  the  posterior  branches, 
as  well  as  just  below  the  crest  of  the  ilium.  Points  of  tenderness  may  be 
also  found  at  various  situations  in  the  course  of  the  nerve  at  the  back  of 
the  thigh ;  sometimes  in  the  popliteal  space,  or  at  the  head  of  the  fibula, 
and  in  the  depression  below  the  external  and  internal  malleoli.  Atrophy 
of  the  muscles  of  the  thigh  is  not  a  rare  consequence  of  the  neuralgia  in 
old  cases,  and  is  sometimes  preceded  by  paresis.  Tactile  sensibility  is 
diminished,  and  areas  of  anaesthesia  or  blanching  of  the  skin  are  occa- 
sional results  of  a  continued  siege.  The  paresis  of  sciatica  is  of  gradual 
appearance,  and  the  patient  may  at  first  slightly  drag  his  leg  or  limb.  In 
some  of  the  old  cases  the  least  movement  of  the  limb  is  attended  by  pain, 
which  is  referred  by  the  patient  to  the  point  where  the  sciatic  nerve  leaves 
the  pelvis.     Such  atrophy  may  follow  inactivity. 

A  curious  feature  of  the  disease  in  some  cases  is  the  appearance  of  pain 
in  different  parts  of  the  limb.  In  the  case  of  a  gentleman  who  came 
to  me  for  advice,  I  found  that  there  were  two  districts  of  pain  :    one 


522  DISEASES    OF    THE    PERIPHERAL    NERVES. 

of  whicli  included  the  upper  part  of  the  sciatic,  the  pain  never  passing 
below  the  middle  third  of  the  right  thigh  ;  the  other  situated  at  the  outer 
side  of  the  leg  of  the  same  side. 

CRURAL   NEURALGIA. 

When  the  pain  is  confined  to  the  anterior  and  lateral  parts  of  the  thigh, 
it  is  properly  included  in  the  cases  called  by  this  name,  but  the  region 
supplied  by  the  crural  and  its  branches,  viz.,  the  inner  surface  of  the  thigh 
and  its  anterior  aspect,  as  well  as  the  inner  part  of  the  leg  and  foot,  is 
more  often  the  seat  of  pain  in  the  lower  extremity  than  any  other  part 
except  that  innervated  by  the  great  sciatic.  This  pain  is  paroxysmal, 
very  severe,  and,  like  that  of  the  cervico-brachial  variety,  most  intense  at 
night.  The  inner  part  of  the  leg  and  foot  are  most  commonly  implicated, 
and  there  is  a  subacute  variety  of  pain  which  exists  between  the  parox- 
ysms. Walking  and  muscular  movements  of  any  kind  are  painful,  and 
the  patient  may  find  it  necessary  to  use  a  crutch,  or  else  is  obliged  to  keep 
quiet.  Foci  of  tenderness  may  be  detected  at  the  point  where  the  crural 
nerve  is  most  superficial,  in  the  groin  at  the  inner  side  of  the  knee,  at  the 
upper  and  inner  edge  of  the  patella,  and  at  various  points  on  the  inner 
side  of  the!  foot  and  leg.  Muscular  atrophy,  which  is  probably  a  result  of 
insufficient  use  of  the  limb,  is  sometimes  a  feature  of  the  disease.  When 
the  pain  is  more  severe  at  the  knee-joint,  we  may  find  an  enlargement  of 
that  articulation,  and  in  some  respects  the  condition  may  resemble  ar- 
thritic inflammation  ;  but  the  cutaneous  hypersesthesia  is  much  greater  than 
in  the  latter  affection,  while  deep  pressure  does  not  produce  the  amount 
of  pain  it  would  in  rheumatism.  In  many  respects  the  pain  may  resemble 
that  of  posterior  spinal  sclerosis. 

THE    VISCERAL   NEURALGIAS. 

The  visceral  neuralgias,  especially  those  found  to  be  connected  with  the 
uterus  and  its  appendages,  come  more  properly  within  the  province  of  the 
gynecologist  than  the  neurologist ;  so  a  complete  description  would  neces- 
sitate a  consideration  of  the  various  pathological  uterine  states  which 
would  be  out  of  place  in  this  book ;  therefore  our  description  must  be  ex- 
ceedingly brief.  The  importance  of  these  latter  forms  of  neuralgia  can- 
not be  over-estimated.  They  are  commonly  of  reflex  origin,  and  depend 
very  often  upon  some  morbid  condition  of  the  uterus  and  ovaries  them- 
selves. As  Anstie  remarks :  "  The  amount  and  force  of  the  peripheral 
influences  which  are  brought  to  bear  upon  the  central  nervous  system  by 
the  functions  of  the  uterus  and  ovaries  are  greater  than  any  that  emanate 
from  the  diseases  and  functional  disturbances  of  any  other  organ  in  the 
body."  The  menstrual  period,  is  that  with  which  neuralgia  of  this  kind 
is,  in  nine-tenths  of  these  cases,  associated.  It  is  essentially  connected 
with  irritability  of  the  pelvic  organs  of  the  female,  either  when  there  is 
amenorrhoea  and  dysmenorrho^a,  or  when  the  generative  apparatus  is  over- 
excited by  immoderate  copulation  or  masturbation,  or  during  the  preg- 
nant state.  When  there  is  any  mechanical  condition  of  narrowing  or 
occlusion  of  the  cervical  canal,  prolapsus  uteri,  iutra-uterine  growths, 


NEURALGIA. 


523 


ulcers  or  reflected  irritatioD,  neuralgia  is  not  at  all  a  rare  accompaniment. 
I  have  found  it  very  often  as  a  symptom  of  general  anaemia,  with  no  ap- 
preciable uterine  disease  whatever. 


OVARIAN   NEURALGIA. 

Ovarian  neuralgia  is  symptomatized  by  excruciating  pains  radiating 
from  these  organs.  It  is  not  necessary  that  there  should  be  derangement 
of  menstruation,  though  such  is  generally  the  case.  The  pain  may  some- 
times be  dull,  but  is  more  apt  to  be  quite  sharp.  It  is  greatly  increased 
by  standing,  or  by  fatigue  following  protracted  use  of  the  lower  extremi- 
ties. Among  sewing-machine  operators  it  is  especially  common,  and  many 
of  my  cases  have  been  of  this  kind.  It  is  generally  connected  with  con- 
stipation or  a  sluggish  condition  of  the  circulation,  sometimes  leucorrhcea, 
hysteria,  and  always  with  a  great  deal  of  weariness  and  prostration.  The 
suffering  may  be  so  intense  and  protracted  as  utterly  to  wear  out  the 
patient,  and  unfit  her  for  any  labor.  It  may  be  bilateral  or  unilateral. 
There  are  various  other  forms  of  neuralgia  which  depend  upon  reflected 
or  local  causes. 

URETHRAL   NEURALGIA. 

This  is  not  infrequently  associated  with  stricture,  gonorrhoea,  or  mas- 
turbation. It  may  be  quite  obstinate  and  of  a  paroxysmal  character,  and 
is  much  worse  at  night.  I  have  found  it  very  often  where  there  has  been 
a  contracted  meatus,  in  which  case  the  pain  ran  up  the  penis.  Vesical 
neuralgia,  which  may  be  connected  with  the  jDresence  of  a  stone,  or  which 
occurs  as  a  result  of  long-standing  cystitis,  is  symptomatized  by  pain  at 
the  neck  of  the  bladder,  where  there  may  be  some  tenesmus. 

RENAL    NEURALGIA,    ETC. 

Renal  neuralgia  cannot  be  diagnosed  with  certainty,  and  probably  the 
pain  is  in  many  cases  due  to  the  presence  of  calculi.  Neuralgia  of  the 
testis  is  symptomatized  by  sharp  pains  of  a  temporary  character ;  and  it  is 
generally  due  to  some  distant  source  of  irritation,  such  as  the  descent  of 
a  renal  calculus,  or  the  presence  of  a  vesical  calculus.  I  have  seen  cases 
which  have  followed  excessive  venery  ;  and  Anstie  reports  a  case  of  epi- 
lepsy in  which  this  form  of  neuralgia  was  undoubtedly  the  exciting  cause. 
Self- abuse  produced  the  "testicular  neuralgia,"  which  in  turn  precipitated 
the  fits.  With  the  pain  there  were  vomiting  and  great  prostration.  Asca- 
rides  in  the  rectum  may  give  rise  to  neuralgia  of  that  gut.  The  pain  is 
nearly  always  about  the  anus  or  just  above  the  sphincter,  and  darts 
upwards.  Cold  or  exposure  are  given  as  causes.  The  breasts  are  often 
the  seat  of  a  very  painful  neuralgia,  which  has  been  called  mastodynia. 
This  is,  in  reality,  a  form  of  intercostal  neuralgia,  in  which  case  the 
anterior  and  middle  cutaneous  branches  of  the  intercostal  of  one  or  both 
sides  are  affected.  It  appears  at  puberty,  or  may  accompany  lactation 
when  the  nipples  are  (tracked.  In  both  these  classes  of  cases  there  must 
be  a  lowered  nervous  condition  ;    and,  according  to  Anstie,  masturbation 


\ 

524  DISEASES    OF    THE    PERIPHERAL    NERVES. 

precedes  the  trouble  in  the  youthful  patient,  while  it  is  extremely  proba- 
ble that  the  strain  upon  the  nervous  system  during  pregnancy  .and  lactation 
is  often  much  greater  than  the  badly-nourished  patient  can  bear.  I  have 
met  with  the  affection  in  perfectly  healthy  patients,  and  am  convinced  that 
the  pain  was  purely  neuralgic;  and  not  dependent  upon  any  inflammatory 
condition  of  the  nipples.  One  of  these  patients  was  a  prostitute,  and  had 
assiduously  followed  her  trade,  meanwhile  losing  sleep,  and  drinking  to 
excess. 

Causes. — For  the  sake  of  conciseness,  I  may  group  the  causes  which 
are  predisposing  and  exciting  under  the  following  several  heads : — 

1.  Hereditary. 

2.  General  diathetic  (anemia,  rheumatism,  alcoholism,  gout,  syph- 

ilis). 

3.  Psychical  (intellectual,  emotional). 

4.  External  (cold,  pressure). 

5.  Sexual. 

6.  Reflex. 

Hereditary  Predisposition  plays  a  most  important  part  in  the  genesis  of 
neuralgia,  so'  important  indeed  that  it  is  difficult  to  find  cases  of  this  dis- 
ease in  whom  there  has  not  been  some  family  history  of  previous  nervous 
trouble.  Insanity,  paralysis,  alcoholism,  or  convulsive  disorders  may  be 
traced  back  ;  and  of  twenty-two  cases  collected  by  Anstie  there  were  but 
five  in  which  there  had  been  no  family  neurotic  history,  and  in  some  of 
these  phthisis  was  found.  This  disease,  according  to  Anstie  and  others, 
seems  to  play  quite  an  important  part  in  the  causation  of  neuralgia  ; 
and  in  one  minutely  detailed  history  given  by  him  the  appearance  of 
tubercular  meningitis  and  other  neuro-phthisical  diseases  followed  the 
engrafting  of  the  pulmonary  trouble  upon  the  neurotic  stock.  Epilepsy 
enters  extensively  into  the  causation  of  many  forms  of  neuralgia,  especially 
epileptiform  tic ;  and  not  only  may  these  other  neuroses  have  appeared 
among  the  progenitors  of  the  individual,  but  they  actually  exist  with  the 
neuralgia. 

Blandford  ^  has  called  attention  to  a  form  of  insanity  which  coexists 
with  neuralgia,  the  pains  subsiding  during  acute  mental  disturbance,  and 
reappearing  with  its  subsidence.  Migraiue  is  too  common  an  accompa- 
niment of  epilepsy  to  need  more  than  a  passing  allusion.  Chronic  alco- 
holism is  associated  with  a  variety  of  neuralgic  headaches  and  pains  in 
the  lower  extremities,  which  are  quite  intense.  Certain  general  diseases, 
which  produce  a  cachectic  condition,  quite  often  give  rise  to  the  disease, 
not  only  by  actual  mechanical  disturbance  of  the  nerve-functions  by  effu- 
sion and  periosteal  disease,  but  through  the  condition  of  mal-nutrition  and 
enfeeblement  of  the  nervous  system  which  originates  in  malaria,  gout, 
rheumatism,  and  syphilis.  The  influence  of  malaria  in  the  production 
of  neuralgia  is  markedly  seen  in  the  South  and  South-west,  where  the 

# 

^  Insanity  and  its  Treatment,  p.  95. 


NEURALGIA.  525 

most  violent  attacks  of  neuralgia  yield  only  to  large  doses  of  quinine  and 
arsenic.  The  neuralgia  is  generally  of  the  facial  variety,  but  it  may  take 
the  sciatic  or  any  of  the  other  forms.  In  many  cases  it  is  periodic,  or 
occurs  in  connection  with  the  chill  and  other  features  of  the  malarial  at- 
tack. In  most  of  the  cases  I  have  seen,  it  followed  generally  after  a  pro- 
tracted siege  of  "fever  and  ague,"  when  there  was  extreme  debility, 
"  bone-ache,"  and  enlarged  spleen. 

Lumbo-abdominal  neuralgia  is  far  from  being  an  uncommon  malarial 
state,  and  is  sometimes  very  apt  to  be  mistaken  for  renal  colic.  Gout  and 
rheumatism  are  not  looked  upon  by  Anstie  as  diseases  which  play  a  very 
important  part  in  the  general  causation  of  neuralgia,  from  which  opinion 
I  am  inclined  to  dissent.  Putting  entirely  out  of  question  the  local  inflam- 
mation of  the  nerve  sheath,  which  is  so  often  a  cause  of  sciatica  and  other 
neuralgias,  I  am  convinced  that  there  are  forms  of  the  disease,  aggravated 
by  changes  in  temperature,  coexisting  with  painful  joints  and  extremely 
acid  urine  which  disappear  under  alkaline  treatment,  and  are  not  clearly 
exam.ples  of  nerve-sheath  inflammation.  Gout,  inducing  very  often  a 
condition  of  general  or  cerebral  anaemia,  has  been  in  my  experience,  a 
very  frequent  cause  of  facial  and  other  neuralgias.  The  condition  of  the 
liver,  which  occasions  cerebral  ansemia,  melancholia,  and  over-loaded 
bowels,  may  also  induce  a  neuralgia  of  a  functional  character.  Not  only 
in  the  tertiary  form  of  syphilis,  but,  long  before  this,  neuralgia  may  often 
be  a  troublesome  symptom.  I  have  had  recently  under  my  care  an  indi- 
vidual who  had  two  years  ago  a  primary  sore,  and  has  since  had  secondary 
symptoms.  A  chancroid,  recently  contracted,  assumed  a  phagedenic  char- 
acter, and  there  were  great  debility  and  severe  neuralgia,  which  succumbed 
under  specific  treatment  and  nourishing  diet.  Profound  ansemia  is  very 
often  found  to  be  the  origin  of  neuralgia  of  various  kinds.  In  women 
who  have  lost  much  blood  during  the  menstrual  flow,  or  in  others  who 
have  become  exsanguined  from  hemorrhoids,  neuralgia  is  not  to  be  looked 
upon  as  an  unusual  complication. 

The  various  constitutional  diseases  just  alluded  to  may  produce  various 
forms  of  neuralgia,  by  inflammation  of  nerve-sheaths,  with  deposit,  or,  as 
in  the  case  of  syphilis,  gummatous  growths ;  or  periostitis  may  make  dan- 
gerous pressure  upon  the  nerve-trunk  at  some  point  where  the  latter  is 
unable  to  withstand  it  without  injury  to  itself.  Syphilis,  in  rare  instances, 
produces  irritation  in  the  nerve-trunks  themselves,  giving  rise  to  pain. 
This  irritation,  however,  much  more  frequently  produces  motor  paralysis 
than  sensory  disturbance.  Mental  overwork,  shock,  and  a  continued  ab- 
normal play  of  the  emotions  are  likely  to  give  rise  to  neuralgia,  and  for 
this  reason  literary  men  and  hysterical  women  suffer  very  frequently. 
The  headache  of  the  overworked  school  child,  compelled  to  overtax  its 
brain,  and  dependent  upon  confinement  in  a  hot  room,  is  far  too  common. 
Want  of  amusement,  deep  grief,  and  the  pursuit  of  one  narrow  line  of 
thought,  are  all  influences  which  lower  the  integrity  of  the  nervous  system, 
and  give  rise  to  this  as  well  as  other  neuroses.  Anstie's  practical  and 
judicious  reasoning  in  regard  to  false  religious  training,  and  the  dangers 


526  DISEASES    OF    THE    PERIPHERAL    NERVES. 

it  may  bring  in  the  way  of  forcing  the  individual  to  become  self-conscious, 
should  suggest  to  the  physician  and  parent  the  necessity  for  avoiding 
everything  in  education  which  promotes  brooding,  causes  the  individual 
to  torture  himself  with  doubts  and  self-accusation,  and  narrows  the  mind, 
thus  depriving  the  nervous  system  of  its  normal  exercise.  Constant  worry 
about  business  and  any  strain  which  demands  an  unusual  expenditure  of 
brain-force  are  causes  of  this  kind.  Exposure  to  cold  and  damp,  par- 
ticularly if  there  be  wind,  is  a  fruitful  exciting  cause  of  neuralgia,  and 
persons  who  are  exposed  to  draughts  in  railroad  cars  and  public  buildings 
very  often  owe  their  attack  to  such  agencies.  Pressure  from  various 
growths,  cystic,  cancerous,  and  gummatous  deposits,  not  rarely  causes  dis- 
tressing and  intractable  neuralgias  ;  but  a  syphilitic  growth  has  been 
known  to  entirely  surround  a  nerve-trunk  without  interfering  materially 
with  its  functions.^  ^Neuromata  very  frequently  give  rise  to  neuralgia. 
8uch  neuromata  sometimes  follow  amputation  or  gross  nerve-wounds,  and 
the  neuralgia  is  generally  relieved  by  extirpation  of  the  nerve-tumor. 
Various  local  troubles  of  a  peripheral  or  remote  nature,  produce  neural- 
gia, and  among  these  may  be  mentioned  carious  teeth,  ascarides,  and  renal 
calculi.  When  carious  teeth  give  rise  to  neuralgia,  it  is  always  very  ob- 
stinate, and  the  cause  may  remain  unsuspected  for  a  long  time. 

Salter  has  observed  cases  of  cervico- brachial  neuralgia  from  bad  teeth  ; 
the  variety  most  frequently  met  with  however  is  facial  neuralgia.  This 
cause  is  ordinarily  supposed  to  account  very  frequently  for  the  head  neu- 
ralgias, and  many  sound  teeth  are  sacrificed  by  the  individual,  while 
there  may  be  neuralgia  of  the  two  lower  branches  of  the  litth  from  other 
causes.  Over-use  of  the  eyes,  and  consequent  fatigue  of  the  muscles  of 
accommodation,  are  supposed  by  some  to  have  much  to  do  with  its  pro- 
duction. KenaJ  or  urethral  calculi,  gonorrhoea,  masturbation,  and  ex- 
cessive venery,  are  all  reflex  causes  of  importance,  and  play  a  part  in  the 
production  of  lumbo-abdominal  and  other  neuralgias.  Uterine  disease 
and  overloaded  bowels,  or  a  fibrous  tumor  in  the  rectum,  may  by  pressure 
often  produce  sciatica  of  a  very  obstinate  variety,  and  aneurism  more 
rarely  makes  pressure  which  gives  rise  to  neuralgia.  Digestive  derange- 
ment and  prolonged  lactation  may  be  mentioned  as  additional  conditions 
which  favor  the  production  of  neuralgia.  As  to  age  and  sex,  it  is  the 
opinion  of  most  authors  that  neuralgia  usually  originates  at  the  age  of 
puberty,  but  the  disease  is  most  common  betweeu  the  twentieth  and  fiftieth 
years.  The  following  table,  presented  by  Erb  (Ziemssen,  vol.  xi.),  pos- 
sesses statistical  value :- 


£3^-"" 

Yalleix. 

Eulenburg. 

Erb. 

Total. 

Period  of  life  up  to  10  years, 

2 

6 

— 

8 

'.    10  to  2U     '• 

22 

19 

14 

55 

"             <<   2U  to  «^U     '' 

e» 

— 

40 

108 

..  yo  to  ^u    " 

67 

33 

39 

139 

„            .<   40  to  5^     " 

64 

23 

29 

116 

«            ««   50  to  «0     " 

47 

14 

14 

75 

"   60  to  70     " 

21 

6 

9 

36 

«   70to8U     " 

5 

— 

1 

6 

296 

101 

147 

543 

^  Huebner  Ziemssen's  Cyclopsedia,  vol.  xii. 


NEURALGIA.  527 

As  to  sex,  Valleix  collected  469  cases,  218  of  whom  were  men  ;  Eulen- 
burg  106,  of  whom  30  were  men;  Anstie  100,  of  whom  33  were  men; 
Erb  146,  84  being  men.  Of  course  there  are  varieties  of  neuralgia  which 
are  confined  more  to  certain  ages  and  sexes.  Migraine  is  more  general 
among  women,  while  sciatica  is  probably  more  often  a  disease  of  males. 
Anstie  considers  facial  neuralgia  to  be  a  disease  of  adult  life.  So 
far  as  climatic  influences  are  concerned,  neuralgia  is  predisposed,  and 
very  often  markedly  affected  by  sudden  changes  in  temperature.  Dr. 
Weir  MitchelP  has  written  a  very  valuable  paper  upon  the  subject, 
which  clearly  shows  the  very  decided  influence  of  modifications  of 
temperature  and  humidity.  His  article  is  based  upon  the  personal 
notes  of  Captain  Catlin  of  the  U.  S.  Army,  who  suffered  from 
stump  neuralgia,  and  who  intelligently  and  carefully  noted  the  influences 
of  atmospheric  changes.  Captain  Catlin's  conclusions  were  as  follows : 
"  I^euralgic  intensity  does  not  seem  to  be  proportioned  to  the  amount  of 
rain-fall.  At  the  exterior  of  a  storm  disturbance  the  pain  is  usually 
severe,  and,  indeed,  at  times  I  have  been  so  far  from  the  disturbed  centre 
as.  to  just  perceptibly  feel  it.  A  storm,  reinforced  by  another  at  an 
angle  of  say  90°,  producing  greater  eccentricities  in  the  curves,  does  not 
seem  to  produce  a  corresponding  intensity  of  duration  of  the  neuralgia." 
He  adds :  "  I  am  unable  to  state  at  what  point  within  the  disturbed  area 
the  pain  would  be  strongest.  The  abruptness  of  the  barometric  fall  does 
not  seem  to  have  much  to  do  with  the  causing  of  pain,  nor  is  the  length 
of  attack  dependent  as  it  seems  on  the  length  of  the  storm." 

Pathology. — Neuralgia  is  always  the  result  of  lowered  functional  ac- 
tivity dependent  upon  the  trophic  disturbance  of  a  sensory  nerve.  This 
is  probably  attended  by  some  change  in  the  posterior  nerve-roots,  which 
is  not  necessarily  inflammatory.  The  morbid  anatomy  of  neuralgia  has 
thrown  but  little  light  upon  the  pathology  of  the  disease,  so  our  conclu- 
sions must  be  based  upon  purely  theoretical  grounds.  Erb,  in  speaking 
of  the  nutritive  disturbances,  says  :  "  In  regard  to  the  ordinary  seat  of  this 
trophic  disturbance,  nothing  accurate  is  known ;  but  it  is  probable  that 
the  seat  varies,  and  this  much  appears  certain,  that  for  the  most  part  a 
definite  group  of  fibres  (or  their  central  terminations)  as  they  are  com- 
bined to  form  a  nerve-trunk  or  branch,  is  affected.  At  Avhat  place  in  the 
length  of  the  nerve  this  is  present  it  is  difficult  to  say,  and  perhaps  may 
be  at  any  length.  The  peripheric  fibrils  may  be  affected  at  various  points 
and  various  lengths  of  their  course,  or  the  posterior  roots  and  their  pro- 
longation in  the  spinal  cord  may  be  the  seat  of  the  neuralgic  trophic 
disturbance ;  or,  lastly,  the  central  fibrils  running  in  the  spinal  cord  or 
brain  may  be  affected  up  to  the  terminal  central  apparatus.  The  inves- 
tigations that  have  hitherto  been  made  have  acquainted  us  with  many 
important  facts,  but  have  furnished  no  very  satisfactory  conclusion." 

The  clinical  features  of  neuralgia  enable  us  to  understand  many  of  the 
phenomena  which  ordinarily  characterize  the  disease,  and  we  are  permitted 

1  American  .Journ.  of  Med.  Science,  April,  1877,  p.  305. 


528  DISEASES    OF    THE    PERIPHERAL    NERVES. 

to  assume  that  lowered  nutrition  from  general  or  local  disease,  reflected 
irritations,  and  mechanical  pressure  enter  into  its  production.  Instead 
of  a  normal  stimulus  being  conveyed  by  a  healthy  nerve  to  the  centre,  the 
nerve  may  be  functionally  impaired  for  conduction,  or  the  centre  so  altered 
in  its  receptive  faculty  that  the  sensation  period  is  grossly  exaggerated.  The 
receptive  faculty  of  the  peripheral  fibrils  may  be  so  exaggerated  that  ordi- 
nary stimuli  are  received  and  transmitted  in  a  painful  form.  Why  the  dis- 
ease should  be  paroxysmal  we  do  not  know. 

Of  late  much  discussion  has  followed  the  presentation  of  a  new  instru- 
ment by  Vigoroux  for  the  treatment  of  neuralgia,  and  the  nerve-current 
theory  has  been  the  subject  of  earnest  inquiry  and  speculation.  In  this 
percuteur  a  small  hammer  is  made  to  tap  the  surface  of  the  body  over  the 
neuralgic  nerve,  and,  while  rapid  tapping  relieves  dull  pain,  slow  tapping 
is  most  efficacious  in  violent  neuralgic  pains.  In  the  healthy  subject  any 
kind  of  tapping  produces  pain  where  none  existed  before.  Granville  and 
Vigoroux,  both  of  whom  claim  to  have  invented  the  instrument  simulta- 
neously, hold  that  neuralgia  is  the  result  of  an  irregular  current  wave 
or  vibration.  , 

Morbid  Anatomy. — It  is  by  no  means  a  matter  of  necessity  that  a 
nerve  which  has  been  the  seat  of  neuralgia  is  found  to  be  changed  in 
structure.  Accidental  atrophy,  hypersemia,  and  indications  of  neuritis 
are  sometimes  exhibited.  Thickening  of  the  nerve  and  sheath  deposits 
in  its  neighborhood,  or  enlarged  vessels,  tumors,  aneurisms,  and  the  like, 
are  occasionally  met  with.  On  the  other  hand,  nerves  have  been  removed 
which  have  been  perfectly  healthy.  In  old  cases  of  neuralgia  the  posterior 
nerve-roots  are  nearly  always  atrophied. 

Diagnosis. — We  may  briefly  sketch  the  character  of  the  symptoms. 
The  i^ain  of  neuralgia  is  paroxysmal  or  dull,  with  paroxysmal  recurrences ; 
rarely  tenderness  upon  pressure,  except  at  certain  situations.  Neuralgic 
pain  is  rarely  constant,  while  that  of  neuritis  is  quite  so.  The  pain  of 
neuralgia  follows  the  course  of  some  nerve,  is  quite  acute,  and  has  a  lanci- 
nating, terebrating,  or  shooting  character.  It  is  also  connected  with  vaso- 
motor changes  in  the  skin.  The  existence  of  a  cause  must  be  considered, 
and  the  fact  whether  "  hereditary  predisposition  "  is  present  or  not.  Facial 
neuralgia  is  very  rarely  mistaken,  and  should  not  be  when  the  fact  is  taken 
into  consideration  that  the  pain  is  generally  referred  to  one  of  the  branches 
of  the  fifth  nerve.  Pleurodynia  is  sometimes  confounded  with  jDleuritis, 
but  the  absence  of  physical  signs  should  be  sufiicient  to  make  the  diagnosis 
clear.  Lumbo-abdominal  neuralgia  is  very  frequently  confused  with  vari- 
ous painful  affections  of  the  viscera.  Among  these  may  be  mentioned  renal 
colic,  the  pain  of  nephritis,  and  intestinal  colic.  Sciatica,  from  its  unilateral 
character,  is  not  likely  to  be  mistaken  for  any  other  aflfection.  The  im- 
portant indication  in  diagnosis  is  to  determine  the  variety  of  neuralgia, 
whether  syphilitic  or  malarial,  whether  due  to  compression  or  connected 
with  neuritis,  or  whether  due  to  enlargement  of,  and  pressure  from,  any  of 
the  abdominal  organs. 


KEURALGIA.  529 

The  following  are  to  be  remembered  and  consulted  for  guidance  in  mak- 
ing a  diagnosis  — 

A.  Cause  ;  history  of  previous  attacks. 

B.  Character  of  pain  ;  paroxysmal,  inconstant. 
C   Aggravation  by  debility  or  faiigue. 

D.  The  presence  of  "  painful  points." 

E.  Its  distribution  (followiog  course  of  nerves). 

F.  Rarely  aggravated  by  pressure,  except  at  limited    points,  which 

correspond  to  superficial  course  of  the  nerve. 

G.  Its  general  unilateral  character. 

Prognosis. — Neuralgia  of  all  kinds  is  more  curable  in  early  life  than 
in  advanced  age,  and  it  may  be  assumed  that,  when  it  has  lasted  for  many 
years,  and  is  severe  in  character,  it  will  be  most  intractable  ;  this  is  espe- 
cially the  case  in  the  disorder  known  as  tic  epileptiform,  which  may  be  said 
to  be  nearly  always  incurable.  In  these  troublesome  cases  even  removal  of 
the  nerve  affords  but  temporary  relief.  When  atrophy  of  muscles  has  taken 
place  the  chance  of  cure  is  very  remote,  and  if  the  cause  be  a  deep  one,  such 
as  pressure  for  instance,  nothing  can  generally  be  done.  There  is  a  bright 
side  of  the  picture  however.  Functional  neuralgias,  or  those  of  the  syph- 
ilitic variety,  readily  succumb  to  proper  treatment ;  and  sometimes  gene- 
ral nourishment  and  the  removal  of  the  exciting  cause  will  speedily  restore 
the  patient  to  his  normal  condition. 

Those  neuralgias  which  develop  later  in  life  are  attended  by  structural 
decay,  arterial  degeneration,  and  are  very  hopeless.  As  to  the  curability 
of  the  varieties  of  neuralgia,  that  of  the  fifth  nerve  is  most  persistent, 
and  intercostal  neuralgia  perhaps  least  so,  whilst  sciatica  holds  a  place 
midway  between  the  two.  As  an  example  of  a  severe  and  intractable 
continued  neuralgia,  connected,  probably  with  angina  pectoris,  I  may 
present  the  case  of 

Lucy  L.  S,  sixty-five  ;  U.S.;  married.  Previous  History. — When  a 
young  child  she  fell,  striking  her  right  eye  on  a  chair-post.  For  several 
days  it  was  supposed  she  had  lost  her  sight,  but  this  was  found  not  to  be 
the  case.  After  this  she  had  pain  in  the  left  side  and  shortness  of 
breath,  whenever  she  attempted  to  run.  At  twenty-one  she  had  an  attack 
of  cerebral  hemorrhage,  which  aflfected  the  right  side,  but  there  was  no 
aphasia.  This  was  accompanied  by  anaesthesia,  which  has  never  entirely 
disappeared.  About  this  time  there  were  diplopia  and  ptosis — the  latter 
symptom  beiag  now  present.  Supposed  pulmonary  trouble  at  twenty- 
four.     Married  at  twenty-five. 

"  Before  birth  of  my  second  child,  I  was  subject  to  dizziness,  and  neu- 
ralgia of  the  fifth  nerve,  which  was  most  intense  in  the  morning. 

When  nearly  twenty-eight,  and  my  second  child  was  a  few  days  old,  I 
'  commenced  to  see  dark  spots,  sometimes  like  black  specks,  again  like 
circles  with  spotted  centres.'  When  this  child  was  three  or  four  weeks 
old,  sharp  pain  commenced  in  right  side  of  the  head.  After  sleep  the 
pain  would  subside,  and  vision  would  improve.  At  intervals  of  from  three 
to  four  weeks,  or  when  tired,  these  blind  attacks  would  return,  accompanied 
either  by  sharp  pain  or  dizziness  in  the  head.  For  the  next  eight  years 
34 


630  DISEASES    OF    THE    PERIPHERAL    NERVES. 

I  was  comparatively  well,  having  occasional  'blind  turns'  when  tired. 
At  these  times  ray  forehead  would  feel  as  if  strings  were  being  pulled  in 
opposite  directions,  and  there  was  much  twitching  in  the  right  eye.  All 
these  years  there  was  some  pain  about  the  heart,  with  palpitation.  _ 

At  forty-one  the  change  of  life  commenced,  and  I  suffered  several  years 
most  intensely. 

All  these  years  there  was  some  difficulty  around  the  heart.  Palpitation 
and  some  pain  at  intervals. 

For  the  past  three  years  pain  has  been  about  equally  divided  between 
bead  and  heart ;  sometimes  commencing  in  one  and  sometimes  in  the 
other.  Some  six  months  ago  pain  seemed  to  be  settling  around  heart 
particularly.  Would  come  on  with  a  chill  and  creeping  sensation  up  the 
spine,  and  would  begin  with  a  whirling  in  lel't  side.  A  palpitation  of  the 
heart  would  come  on  if  excited  or  tired.  Outward  applicitions  and 
medicine  taken  seemed  to  drive  pain  across  from  left  side  to  right  shoulder. 
Would  go  into  right  side  of  the  head;  follow  down  right  arm  into  hand.  Also 
into  left  arm  and  hand.  Haud^  have  been  much  drawn  up,  and  streaked 
with  red.  When  pain  was  in  face  it  would  be  spotted  red  and  wiiite  on 
right  side  only.  When  severest  in  side  and  heart,  eyes  became  set  in 
head;  face  livid,  and  blood  would  settle  under  nails.  After  enduring 
pain,  tremble  much  in  limbs." 

I  saw  the  patient  daring  the  past  spring,  and  found  her  to  be  a  rather 
spare,  badly-nourished  woman,  and  she  presented  the  following  symp- 
toms : — 

Objective. — The  right  eye  was  examined  and  found  to  be  sightless  ;  the 
retina  was  the  seat  of  an  old  neurids,  with  atrophy  of  the  disfk.  There 
was  slightly  developed  ptosis  of  this  eye,  and  some  keratitis,  corneal 
opacity,  and  ulceration,  and  she  was  obliged  to  wear  a  shade  The 
right  side  of  the  face  was  slightly  anse<thetic  and  analge-i-;.  ^Esthesio- 
meter  contact  and  extremes  of  temperature  were  not  readily  perceived. 
The  same  was  the  case  in  the  skin  of  the  right  arm,  forearm,  and  hand, 
but  more  decidedly  the  latter  The  hand  presented  the  appearances  to 
be  hereafter  described  (see  article  upou  Nhuritis),  and  was  markeilly 
anresthetic,  and  the  skin  showed  evidence  of  impaired  nutrition.  The 
right  lowt-r  extremity  was  in  much  better  condition.  There  was  very 
slight  loss  of  motor  power  on  the  right  side. 

Subjective.. — She  now  has  attacks  of  severe  facial  and  cervico-brachial 
neuralgia  which  come  on  every  two  or  three  weeks,  and  has  had  one  within 
a  dav  or  two;  there  is  still  some  tenderness  left  in  various  parts  of  the 
face  and  right  upper  extremity.  The  pain  seems  most  intense  in  the 
upper  branches  of  the  fifth,  and  has  never  affected  the  inferior  maxillary 
to  a  decided  degree.  The  arm  pain  and  head-pain  are  simultaneous  in 
their  onset,  and  are  preceded  by  the  ordinary  prodromata  of  an  attack  of 
this  kind.  They  are  always  paroxysmal,  and  st'Ciu  to  reach  a  climax  and 
then  subside.  During  the  attack  the  eye  is  seemingly  "  f  treed  forward.s." 
After  the  attack  she  is  entirely  free  from  pain.  With  the  seizure  there 
is  cardiac  trouble,  and  respiratory  trouble  which  suggests  some  impair- 
ment of  the  pneumogastric. 

She  never  has  convul.-i ons  or  vomiting,  and  there  is  no  deep,  localized 
pain  at  any  point  in  the  superior  aspect  of  the  cranium ;  but  all  pain 


NEUEALGIA.  531 

at  this  point  is  superficial,  and  would  evidently  come  under  the  head  of 
hypersesthesia. 

In  this  case  there  is  a  decided  hereditary  history  of  nervous  disease. 

Treatment. — In  nine-tenths  of  the  cases  of  neuralgia  the  manage- 
ment of  the  disease  should  be  undertaken  with  the  assumption  that  the 
pain  is  due  to  lowered  functional  Hctivity  and  depressed  tone  ;  and  while 
local  treatment  is  not  to  be  forgotten,  it  is  absolutely  imperative  that  the 
patient  should  be  supported,  and  that  drugs  which  improve  the  nutrition 
of  the  nervous  system  should  be  selected.  It  is  well  to  minutely  inquire 
into  the  existence  of  other  disease,  and  reference  to  what  I  have  already 
said  about  etiology  will  furnish  the  reader  with  such  hints  as  may  be 
necessary.  Should  menstrual  irregularities,  gastric  derangement,  or  con- 
stitutional diseases  be  found,  it  is  well,  I  may  say  absolutely  necessary, 
that  these  should  be  corrected  before  any  local  treatment  is  to  be  under- 
taken. 

Neuralgic  pain  is  very  variable  ;  and  although,  for  my  present  purpose, 
I  shall  make  use  of  two  expressions  to  denote  its  character  there  is  much 
that  must  necessarily  remain  unsaid  in  regard  to  its  variation  and  pecu- 
liarities. 

I  shall  describe  the  pain  of  neuralgia  as  coarse  and  fine,  two  divisions 
which,  though  somewhat  arbitrary,  are  useful  when  we  speak  of  treat- 
ment. Fine  neuralgic  pains  may  be  said  to  be  those  of  a  sharp  paroxys- 
mal character,  leaving  behind  no  points  of  tenderness,  and  entirely  un- 
connected with  any  suspicion  of  neuritis.  Coarse  neuralgic  pains  maybe 
said  to  include  the  brusque  pains,  which  bring  local  tenderness  and  sore- 
ness, and  are  aggravated  by  movement.  The  former  are  those  which 
sometimes  occur  during  migraine  and  functional  neuralgia  of  the  lighter 
kinds  ;  while  the  coarse  pains  may  be  often  the  result  of  sciatica,  in  which 
the  movement  of  the  limb  in  walking  or  the  pressure  of  the  chair  is  suffi- 
cient to  give  rise  to  them.  In  one  form  of  the  latter  our  treatment  should 
be  quite  negative,  and  of  a  character  which  necessitates  the  use  of  coun- 
ter-irritants, such  as  blisters  and  the  actual  cautery  ;  while  the  former  is 
best  treated  by  remedies  which  either  increase  the  blood-supply  of  the 
nervous  centres  and  improve  their  tone,  or  allay  reflex  irritability.  The 
treatment  of  facial  neuralgia  or  raigraiue  should  be  the  following :  The 
use  of  diffusible  stimulants  ;  muriate  of  ammonia  being,  perhaps,  one  of 
the  best.  It  should  be  given  in  large  doses  quite  frequently,  beginning 
with  from  twenty  grains  to  a  drachm,  which  should  be  repeated  every 
hour  during  the  attack.  Coffee  and  tea,  or  their  alkaloids,  are  often  ser- 
viceable ;  or  we  may  prescribe  guarana,  which  is  a  very  valuable  remedy, 
in  doses  of  half  a  drachm  to  a  drachm  every  hour.  I  have  never  wit- 
nessed any  bad  results  from  the  use  of  this  drug,  even  when  quite  large 
doses  were  taken.  The  powder  is  the  best  preparation.  Tr.  belladonna 
given  in  small  repeated  doses,  does  much  good  if  the  disease  be  of  a  re- 
flex character.  The  drugs  recommended  for  this  variety  of  neuralgia 
are    quite  as   numerous   as   most   of  them   are  useless.     The   alkaloids 


632 


DISEASES    OF    THE    PERIPHERAL    NERVES. 


Fig.  66. 


Conv.  Tihitdis 


Deep  Peroiiealt 


NEURALGIA.  533 

SuPERTiciAL  Points  and  CniANEous  Areas  op  Nerve  Distribution. — 1,  2,  3,4.  Points  for  galvani- 
zation of  fifth  nerve.  5.  Brachial  plexus.  6.  Musculo-eutaneous.  7.  Median.  8, 9.  Ulnar.  11, 
12,  Crnral.  13.  Peroneal.  14.  Tibial.  1.5.  Occipital.  16.  Radial.  17,  18.  Sciatic.  19  Popliteal 
30.  Peroneal,  ac.  Acromial.  Cir.  Circumflex.  Int.  h.  Internal  humeral.  Ext.  c.  External  cu- 
taneous. Int.  c.  Internal  cutaneous,  c.  p.  Cutaneous  palmaris.  p.  u.  Palmaris  ulnaris.  m. 
Median.  Sad.  Radial,  u.  Ulnar.  Mus.  Sp.  Musculo-spiral.  Ilio-By.  Iliohypogastric.  I.  I. 
Ilio-inguinal.  Lat.  Cut.  Lateral  cutaneous.  E.  S.  External  spermatic.  Luni.  I.  Lumbo-iagui- 
nal.  Pos.  C.  Posterior  cutaneous,  ob.  Obturator.  Com.  p.  Communicating  peroneal  In.  sa. 
Internal  saphena.  Sup.  p.  Superficial  peroneal,  cpm.  Posterior  median  cutaneous.  Qjp.  Cuta- 
neous plantaris  proprius.    PU.  Plantaris  lateralis. 

daturine  and  conia  have  been  used  in  obstinate  cases  of  tic  epileptiform 
•with  varying  degrees  of  success,  but  great  care  should  be  taken.  I  have 
often  broken  up  aa  attack  of  ordinary  facial  neuralgia  with  a  cup  of 
strong  hot  tea,  or  even  a  cup  of  hot  water  ;  and  now  have  a  patient  who 
has  been  in  the  habit  of  taking  an  emetic,  which  has  almost  immediately 
given  her  relief.  Cannabis  indica,  either  in  the  form  of  the  extract  or 
tincture,  is  of  service  when  guarana  fails.  Its  use  should  be  continued 
for  several  months.  If  the  neuralgia  be  malarial,  a  fair  dose  (say 
twenty  grains)  of  quinine  rarely  fails  to  abate  the  paroxysm.  As  local 
applications,  various  stimulating  liniments  are  used,  the  best  I  know 
being  the  compound  soap-liniment;  or  a  mixture  of  chloroform,  tr. 
aconite  and  camphor;  an  ointment  of  veratria  or  of  chloral  and  camphor 
sometimes  affords  relief,  and  I  have  witnessed  the  good  effects  of  a  tinc- 
ture made  of  the  berries  of  the  belladonna.  The  blister  or  actual 
cautery  may  be  brought  into  requisition  if  painful  points  are  found,  and 
I  have  been  in  the  habit  of  using  the  ether  spray  just  in  front  of  the 
ear  in  migraine.  In  tic  douloureux  I  am  convinced  there  is  no  better 
remedy  than  gelsemiiium  given  in  large  doses,  beginning  with  i^lviij  to 
TTLxv  of  the  tincture  or  fl.  extract.  My  friends  Drs.  Kinnicutt  and 
Clymer  have  both  mentioned  to  me  the  details  of  cases  where  by  accident 
the  patient  had  taken  toxic  doses  of  this  drug.  In  one  of  these  the 
disease  entirely  disappeared  after  the  alarming  effects  of  the  remedy  had 
passed  away.  Croton-chloral,  which  has  lately  been  recommended  for 
facial  neuralgia,  I  am  convinced  has  been  overpraised ;  I  have  given  it  a 
fair  trial,  and  have  rarely  found  it  of  any  use.  If  it  is  employed  twice  a 
day  in  twenty-grain  doses,  it  will  do  more  good  than  in  the  small  repeated 
doses.  The  removal  of  carious  teeth  is  often  followed  by  speedy  disap- 
pearance of  the  disease.  Should  the  face  become  tender,  as  it  not 
uncommonly  does,  the  patient  should  be  directed  to  keep  it  carefully 
protected  by  cotton-batting ;  and  if  painful  points  remain  in  the  roof  of 
the  mouth  or  gums,  they  may  be  lightly  touched  with  the  hot  glass  rod 
or  iron.  The  treatment  of  cervico-brachial,  cervico-occipital,  and  other 
neuralgias  of  the  trunk  may  be  managed  after  very  much  the  same  plan. 
In  each  particular  case  of  course  the  treatment  varies.  If  there  be  a 
diathetic  condition,  such  as  syphilis,  mercurial  inunctions,  baths  and 
specific  treatment  are  to  be  made  use  of  in  conjunction  with  local  appli- 
cations. The  advantage  of  large  doses  of  quinine  in  cachectic  headaches, 
as  well  as  in  intercostal  or  lumbo-abdominal  neuralgia,  especially  if  there 
be  an  herpetic  eruption,  I  have  mentioned.     In  these  forms,  as  well  as  in 


534  DISEASES    OF    THE    PERIPHERAL    NERVES. 

ovarian  neuralgia,  the  use  of  local  cold,  such  as  may  be  obtained  by 
ice-bags,  or  the  application  of  blisters,  is  very  efficacious.  The  actual 
cautery,  employed  to  make  sweeping  strokes  along  the  course  of  the 
nerve,  or  down  the  back  on  either  side  of  the  spinous  processes,  and  in 
paths  which  run  at  right  angles  to  the  longitudinal  "stripes,"  may  be 
brought  into  requisition,  and  applied  twice  or  thrice  weekly.  Sciatica 
sometimes  demands  most  obstinate  treatment.  The  actual  cautery,  and 
even  nerve-stretching,  may  be  necessary;  but  in  the  majority  of  cases 
galvanization  of  the  nerve  does  great  good,  and  should  be  faithfully  tried 
before  anything  else  is  done.  In  neuralgia  of  the  rectum  it  will  often  be 
found  that  stretching  of  the  sphincter  ani  will  effect  a  rapid  cure,  espe- 
cially when  fissure  exists. 

Electricity  affords  very  decided  relief  in  this  disease ;  and  galvanism, 
wlien  judiciously  employed,  rarely  fails  to  modify,  if  not  cure  neuralgia. 
In  facial  neuralgia  it  should  be  applied  to  the  nerve  by  small  sponge- 
covered  electrodes,  one  pole  being  placed  just  behind  the  condyle  of  the 
jaw,  and  the  other  held  for  a  few  minutes  over  the  supra-orbital  and 
infra-orbital  foramina,  or  over  the  symphysis  of  the  lower  jaw.  The 
current  should  be  the  direct  (from  positive  to  negative,  the  negative  pole 
peripheral).  The  plates  of  Morgan,  and  the  suggestions  of  Zierassen, 
will  enable  the  reader  to  comprehend  the  situation  of  the  points  corres- 
ponding to  the  superficial  course  of  the  various  nerve-trunks,  so  that  they 
shall  be  brought  most  readily  under  the  influence  of  the  current.  Fara- 
dism  of  the  intercostal  nerves,  and  of  regions  of  distribution  of  terminal 
filaments  of  other  nerves  in  various  neuralgias,  is  of  great  service,  and 
rarely  fails  to  affjrd  relief  in  sciatica.  I  iiave  seen  pleurodynia  disap- 
pear in  ten  minutes  after  the  use  of  the  faradic  current.  The  following 
case  shows  the  benefit  of  electrical  treatment. 

Mr.  S.  After  constant  exposure  during  the  war,  the  patient  con- 
tracted a  low  typhoid  fever  which  left  him  weak  and  emaciatir'd  for  a 
long  time.  Since  1868  he  has  had  twinges  of  pain  down  the  back  part  of 
the  leg,  which  have  left,  him  in  a  perpetual  state  of  misery,  with  only 
occasional  intervals  of  several  months  when  he  is  absolutely  free  from 
pain.  In  winter  his  trouble  is  worse,  and  any  exposure  will  i.nmediately 
producrf  a  severe  attack  of  neuralgic  pain.  Any  indiscretion  in  his  diet 
will  also  be  followed  by  the  sciatica.  He  had  gone  through  the  usual 
siege  of  medication,  including  morphine,  hypodermics,  and  stitnuhiting 
lotions.  He  came  to  me  in  July,  1871,  when  I  made  applications  of 
galvanism  to  the  nerve  by  the  conical  sponge-electr(jde,  the  spijnge  being 
held  firmly  over  the  obturator  foramen.  At  the  first  vi:-it  his  pain  was 
exces.-ive,  but  after  fifteen  minutes  application  he  left,  feeling  a  sens^^  of 
relief  which  he  had  not  known  for  months.  Two  months  and  a  half  of 
this  treatm-nt  were  sufficient  to  dispel  the  pain,  which  did  not  recur. 
Four  months  afterwards,  he  m  ide  a  visit,  when  he  stated  that  he  had  not 
had  any  return. 

L?s3  than   one  year  ago    Granville  described  an  instrument  fjr  the 


NEURALGIA. 


535 


treatment  of  neuralgia,  which  effects  the  mechanical  transmission  of 
shocks  to  a  nerve  which  may  be  the  seat  of  neuralgic  pain.  I  have  not 
seen  Granville's  instrument,  which  consists  of  a  hammer  driven  by  a 
rachet  wheel,  and  so  regulated  that  rapid  or  slow  shocks  may  be  made. 
I  have,  however,  carefully  followed  out  his  experiments  with  an  instru- 
ment which  consits  of  a  tuning-fork,  (c)  vibrated  by  electricity,  and  solidly 

Fig.  67. 


mounted  upon  a  hoard.  The  board  is  provided  with  an  arm,  (h)  which 
can  be  applied  to  the  superficial  part  of  the  nerve.  By  means  of  set  screws 
(a.  a.)  coarse  or  rapid  vibrations  may  be  produced,  (d)  is  an  electro- 
magnet. In  acute  pain  the  slow  vibrations  are  communicated  to  the 
nerve  trunk,  destroying  the  irregular  character  of  the  painful  impression, 
and  often  affording  instant  relief.  The  curious  reflex  phenomena  that 
result  sometimes  are  indicative  of  a  very  profound  nervous  impression. 
In  my  personal  experiments  I  was  able  to  provoke  a  synchronous  vibra- 
tion in  the  tensor  tympani  muscle  with  subjective  throbbing  and  noises; 
and  an  ocular  impression  manifested  in  momentary  flashes  &uch  as  are 
produced  by  the  galvanic  cuirent. 


536  DISEASES    OF    THE    PERIPHERAL    NERVES. 

In  the  treatment  of  neuralgic  attacks  the  hypodermic  syringe  has 
played  a  very  important  part.  I  have  no  doubt  that  it  has  been  abused, 
and  I  have  become  painfully  aware  that  individuals  have  thus  acquired 
the  habit  of  opium  and  morphine  self-administration.  For  the  radical 
cure  of  certain  varieties  of  neuralgia,  the  hypodermic  syringe  has  no 
equal.  Dr.  T.  M.  B.  Cross,  was  the  first,  I  believe,  to  use  deep 
injections  of  morphine  in  sciatica.  He  has  recommended  that  the 
point  of  the  syringe  needle  be  carried  down  to  the  sheath  of  the  nerve, 
and  the  contents  of  the  barrel  gradually  expelled.  Strange  to  say,  very 
few  accidents  have  followed  its  use,  although  the  wounding  of  an  artery 
is  not  an  impossibility.  Chloroform  has  been  used  hypodermically  by  Bar- 
tholow,^  and  with  great  success,  and  though  I  have  produced  abscesses 
in  this  way,  I  am  inclined  now  to  acknowledge  its  value  as  a  therapeutic 
measure.  Morphine,  and  atropine,  ergotine,  and  other  alkaloids  are  con- 
stantly used,  and  sometimes  afford  relief,  which  is  generally  temporary, 
but  occasionally  permanent.  The  general  treatment,  is  however,  all-im- 
portant, and  iron,  strychnine,  arsenic  cod-liver  oil,  and  phosphorus 
rank  high  as  valuable  remedies.  I  have  spoken  of  quinine.  I  may  add 
that  when  given  continuously,  either  in  combination  or  alone,  it  cannot 
fail  to  do  good.  Tonga,  the  new  Fiji  remedy,  has  been  recently  recom- 
mended. It  is  excellent,  especially  in  facial  neuralgia,  and  may  be 
given  in  doses  of  from  n\^x — n\^xx  every  two  hours  until  relief  is  obtained. 
Phosphorus  always  does  good,  except  in  forms  of  neuralgia,  which  are  not 
directly  dependent  upon  depraved  nutrition,  and  are  due  to  cold  or  at- 
tended by  inflammatory  conditions.  Marey  ^  has  recommended  the  nitrate 
of  aconitia  for  facial  neuralgia.  He  has  cured  cases  very  rapidly  by  the 
administration  of  a  quarter  of  a  milligramme  several  times  a  day,  in- 
creasing the  dose  until  the  patient  finally  took  as  much  as  two  milli- 
grammes. Gubler  also  used  aconitia  in  facial  neuralgia  with  much 
success.  Dr.  S(^guin  some  time  ago  called  attention  to  its  virtue  in  neural- 
gic affections  of  the  fifth  nerve.  It  should  be  given  in  doses  of  ykth  of  a 
grain,  and  repeated  until  the  face  becomes  decidedly  numb.  The  solution 
used  by  Seguin  is  as  follows : 

B  Duquesnel's  aconitia  gr.  one-twelfth. 

Alcohol,     1    .  .  _  . 

x^,        .       ^  a  a  5  J- 

Glycerine,  J  ^  -' 

Aq.  menth.  pip.  ad  ^  ij.     M. 

Sig. :  One  teaspoonful  three  times  a  day. 

I  have  used  it  in  the  form  of  saturated  tablets,  prepared  by  Caswell, 
Hazard  &  Co.  of  this  city. 

In  cases  of  headache  of  the  congestive  variety  it  will  be  found  that 


^  Mat.  Medica  and  Therapeutics,  p.  321,  et  seq. 
2  Tbese  de  Paris,  1880. 


NEURALGIA.  537 

tincture  of  Cannabis  Indica  brought  to  the  physiological  point  does  much 
good.  Thompson's  solution  is  the  best  preparation.^  Salt  air,  with  alter- 
nations of  mountain  air,  nourishing  diet,  which  should  include  a  large 
proportion  of  non-nitrogenous  food,  attention  to  the  daily  habits,  the 
removal  of  fecal  accumulations,  and  the  re-establishment  of  menstrual 
regularity  are  of  the  greatest  importance,  and  should  be  accomplished  if 
possible. 

R  Phosphori  gr.  ss. — iss. 
Alcohol  absolut.  q.  s.  ut.  diss. 
Ess.  menth.  pip.  q.  s. 
Glycerinse  ad.  ^  iv. — M. 
Sig :  A  teaspoonful  after  eating. 


538  DISEASES    OF    THE    PERIPHERAL    NERVES. 


CHAPTER    XYII. 

DISEASES  OF  THE  PERIPHERAL  NERVES  (Continued). 

NEURITIS. 

Symptoms. — Inflammation  of  a  nerve  is  expressed  chiefly  by  sore- 
nefs  and  tenderness,  and  not  by  darting  or  paroxysmal  pain,  which  con- 
stitutes neuralgia.  When  confined  to  the  nerve  trunk,  various  depraved 
conditions  of  sensibility,  motility,  and  trophism  may  follow,  which  are 
expressed  by  cutaneous  and  muscular  changes  ;  and  the  course  of  the 
nerve  can  usually  be  marked  with  great  exactness,  for  pressure  produces 
great  pain.  The  skin  may  be  red  or  the  seat  of  bullous  or  pemphigous 
eruptions.  Of  course  very  much  depends  upon  the  character  and  impor- 
tance of  the  nerve  afiected.  Some  of  the  nerves  of  sensibility,  such  as 
the  fifth,  when  subject  to  neuritis,  are  followed  by  symptoms  diflTerent  from 
those  which  occur  when  the  seventh  or  one  of  the  mixed  nerves  is  affected. 
Peripheral  inflammation  of  the  external  portion  of  the  seventh  is  often 
the  cause  of  facial  paralysis,  and  neuritis  of  the  fifth  may  occasion  disor- 
ders of  sensibility  as  well  as  ulceration  of  the  cornea  and  other  trophic 
phenomena.  With  neuritis  there  is  not  infrequently  loss  of  tactile  sensi- 
bility and  sense  of  appreciation  of  temperature,  though  in  the  beginning 
the  skin  is  hypsrseithetic,  and  the  pain  is  aggravated  by  contact  with 
cold  or  hot  substances.  Eib  speaks  of  acute  and  chronic  neuritis,  the 
former  depending  upon  traumatism,  sloughing,  or  cancer,  and  begisming 
with  a  chill,  followed  by  fever,  headache,  and  sleeplessness.  The  pain 
commences  in  the  affected  member,  and  extends,  until  finally  chronic 
neuritis  is  progressive,  the  inflammation  spreading,  and  involving  new 
nerves.  This  extension  may  be  recognized  by  the  fresh  appearance  of 
pain  in  new  localities  ;  by  painful  points  (Valleix's)  at  new  regions,  by 
diff'Tcnce  in  the  form  of  pain,  and  by  variations  attending  pressure  ;  the 
■whole  limb  is  affected.  This  author,  as  w^ell  as  Mitchell,  considers  that  it 
is  mostintenss  at  night,  and  that  it  is  augmented  by  movement.  Mitchell 
has  observed  intense  hysterical  excitment,and  even  delirium.  A  red  line 
usually  marks  the  course  of  the  aflTocted  nerve,  and  there  may  be  patches 
of  herpes  or  pemphigus,  or  the  skin  may  be  oedematous.  In  one  case,  ob- 
served at  the  Epileptic  Hospital,  the  patient,  a  negress,  presented  symp- 
toms of  neuritis  of  the  anterior  tibial  nerve,  and  the  skin  of  the  fore  part 
of  the  right  leg  was  tense,  shiny,  and  exquisitely  sensitive.  A  marked 
rigor  ushered  in  its  development,  and  there  were  sub-equently  nausea  and 
vomiting.  Her  pulse  was  feeble  and  rapid,  and  she  could  not  .«leep,  and 
entirely  lost  her  appetite.  There  was  no  inflammation  whatever  of  the 
skin  or  muscular  tissue,  and  the  acute  pain  subsided  in  a  few  weeks,  but 


NEURITIS. 


539 


there  remained  a  condition  of  great  tenderness.  Hot  and  cold  applica- 
tions increased  the  pain. 

Paralysis  may  follow,  and  is  by  no  means  uncommon.  The  patient 
generally  recovers  in  a  month  or  so,  and  sometimes  in  a  shorter  time,  but 
the  neural  condition  never  entirely  disappears.  In  the  chronic  form  the 
onset  may  be  gradual  or  spontaneous,  or  follow  an  acute  attack.  I  have 
sufficiently  sketched  the  symptoms,  and  will  only  add  that  muscular 
cramps,  tremor,  or  permanent  contractures  sometime?  form  very  distress- 
ing sequelae,  and  with  these  there  is  paralysis.  Anaesthesia  or  hyperses- 
thesia  is  connected  with  neuritis,  the  former  being  of  late  appearance. 
Erb  calls  attention  to  the  comparative  immunity  of  the  motor  nerves,  as 
paralysis  does  not  follow  until  after  a  long  train  of  sensory  disturbances, 
but  reflex  disturbances  are  not  uncommon.  These  may  consist  in  remote 
nerve  pain,  cramps  of  distal  muscles,  or  hysterical  attacks.  The  electric 
excitability  in  the  early  stages  is  exaggerated  later,  or  it  is  lost,  and  if 
there  be  paralysis  there  is  very  marked  muscular  atrophy  as  a  conse- 
quence, and  electric  contractility  disappears  altogether.  By  far  the  most 
interesting  changes  are  those  of  a  trophic  character.  Weir  Mitchell  has 
presented  a  most  complete  description  of  these  structural  alterations. 
The  finger-nails  lose  their  normal  character,  and  become  horny  and  curved, 
and  the  skin  becomes  rough  and  is  sometimes  exfoliated. 

As  additional  evidences  of  this  defective  nutrition,  "  hang  nails," 
cracking  of  the  skin  and  other  slight  changes  from  its  healthy  condition 
are  striking  indications.     The  illustration  (Fig.  68)  which  I  produce  is 

Fi^.  68. 


Trophic  Change  of  the  Skin. 

from  the  photograph  of  a  patient  whose  hand  had  been  anaesthetic  for 
some  years.  The  skin  is  hard,  the  palmar  furrows  are  sharp  and  exag- 
gerated, and  the  bases  are  red  or  purple,  somewhat  resembling  the  same 


540  DISEASES    OF    THE    PERIPHERAL     KERVES. 

appearance  in  the  cutaneous  flexure  of  the  knee,  elbow,  or  other  articu- 
lating parts  in  certain  forms  of  chronic  eczema. 

Causes. — The  acute  variety  is  dependent  upon  injuries  of  various 
kinds.  I  have  seen  one  case  which  followed  a  carbuncle  situated  upon 
the  inner  surface  of  the  forearm,  and  Mitchell  reports  several  cases  fol- 
lowing gunshot  wounds.  Flying  splinters,  fractures,  and  blows  are 
various  traumatic  causes,  while  the  extension  of  cancerous  disease  or 
sloughing  may  produce  a  neuritis.  Cold,  rheumatism,  and  syphilis  enter 
into  the  etiology  of  the  affection,  and  Mitchell  has  produced  a  neuritis 
by  the  local  application  of  ice.  In  one  case  of  facial  spasm,  for  which  I 
used  the  ether  spray,  I  was  disagreeably  surprised  to  find  a  remaining 
neuritis  of  the  portio  dura,  which  lasted  for  some  time. 

Beau  has  directed  attention  to  forms  of  neuritis  of  the  intercostal 
nerves  which  undoubtedly  arose  from  pleurisy  and  pleuro-pneumonia. 
Typhoid  fever,  diphtheria,  and  other  diseases  of  a  febrile  nature  are  not 
infrequently  attended  by  neuritis,  and  in  one  case  of  typhus,  reported  by 
Bernhardt,  a  neuritis  involved  the  musculo-spinal  nerve. 

Morbid  Anatomy  and  Pathology. — Inflammation  of  a  nerve- 
trunk  produces  very  decided  changes  in  its  appearance.  It  becomes 
swollen,  is  of  a  pinkish  hue,  and  there  is  often  an  exudation  which  is 
found  between  the  fasciculi ;  this  may  be  also  of  a  reddish  color.  The 
microscopical  appearance  of  the  nerve  is  still  more  characteristic.  The 
nerve-fibres  undergo  marked  changes  ;  the  axis,  cylinder,  and  the  medul- 
lary contents  are  disintegrated;  the  neurilemma  maybe  distended  by 
serous  exudation,  and  the  blood  vessels  are  enlarged  and  in  places  rup- 
tured, so  that  blood-elements  may  be  found  scattered  in  different  regions. 
In  later  stages  there  may  be  atrophy  or  fatty  degeneration.  In  chronic 
neuritis  these  appearances  of  advanced  degenerative  changes  are  found 
to  consist  in  proliferation  of  connective  tissues,  and  this  takes  place 
as  an  interstitial  formation.  Degeneration  of  the  minute  nerve-ele- 
ments, deposition  of  oil-globules,  and  sclerosed  patches  are  found  in  old 
cases. 

If  the  inflammatory  action  be  very  severe,  the  nerve  will  be  found  to 
be  completely  destroyed  by  sloughing.  The  nerve  may  be  found  to  be  the 
seat  of  enlargements,  which  are  to  be  seen  at  different  localities  in  its  course, 
and  at  each  of  these  points  there  may  be  a  different  kind  of  change.  In- 
flammation of  a  nerve-trunk,  as  I  have  said,  is  first  attended  by  sensory 
changes,  which  may  be  local,  or  in  other  parts  ;  as  the  result  of  reflected 
irritability ;  afterwards  trophic  changes  may  result  either  from  the  pro- 
duction of  some  pressure  upon  other  parts,  or  through  loss  of  function  of 
the  nerve  itself. 

Diagnosis. — The  limitation  of  the  pain,  its  aggravation  by  pressure, 
its  constancy,  and  its  character,  enable  us  to  generally  distinguish  it  from 
neuralgia.  In  chronic  neuritis  it  is  not  so  easy  to  make  such  a  diagnosis. 
The  painful  points  found  in  neuralgia  may  be  mistaken  for  the  sensitive 
spots  in  neuritis.  I  have  seen  very  few  cases  in  which  the  pain  of  neuritis 
was  not  constant,  and  this  is  not  the  case  in  neuralgia,  which  is  essentially 


NEURITIS.  541 

a  paroxysmal  disease.  Painful  sweliiag  of  the  nerve  and  paralysis  of 
muscles  supplied  are  also  evidences  of  neuritis,  which  will  aid  us  in  dis- 
covering the  nature  of  the  affection. 

Muscular  rheumatism  has  been  spoken  of  by  Erb  as  a  condition  with 
which  the  disease  under  consideration  may  be  confounded.  I  consider 
such  a  distinction  to  be  a  refinement  of  diagnosis  which  cannot  be  made. 
"  Muscular  rheumatism  "  is,  after  all,  a  low  grade  of  diffused  neuritis, 
and  the  most  we  can  do  is  to  discover  the  cause  of  such  pain. 

Erysipelas,  thrombosis,  and  embolism  are  distinguished  by  the  evidences 
of  subcutaneous  swelling,  oeedema,  etc.,  and  by  their  somewhat  diffuse 
character. 

The  presence  of  a  traumatism  should  be  taken  into  account,  and  its 
nature  investigated. 

Prognosis. — Structural  alteration  of  a  nerve  must  follow  an  inflama- 
tion  such  as  has  been  described,  and  unless  the  symptoms  have  been  very 
slight,  there  is  a  tendency  to  continuance,  so  that  an  attack  of  acute  neuritis 
assumes  a  chronic  character.  If  the  inflammation  has  advanced  centrally, 
so  that  a  new  plexus  is  involved,  the  prognosis  is  very  bad.  Treatment 
has  much  to  do  in  some  cases  with  prognosis. 

Treatment. — To  Mitchell  we  are  indebted  for  excellent  directions 
for  the  management  of  neuritis.  He  tried  elevation  of  the  leg  or  arm 
while  bladders  of  ice  were  applied  to  every  part  of  the  limb,  and  i^  gr. 
hypodermic  doses  of  atropia,  with  i  gr.  doses  of  sulph.  of  morphia,  were 
injected  every  four  hours,  or  oftener.  He  has  used  leeches,  so  that  con- 
siderable local  abstraction  of  blood  should  take  place.  Perfect  quiet  is 
highly  important,  and  he  recommends  splints  for  the  purpose.  I  have 
used  the  plaster  bandage  in  a  way  to  leave  the  course  of  the  painful  nerve 
exposed.  The  actual  cautery  is  invaluable,  especially  when  the  disease 
is  chronic,  and  it  should  be  freely  applied  along  the  painful  tract.  Fara- 
dization does  good,  but  I  have  no  faith  in  the  galvanic  current,  which 
only  increases  the  pain.  Hypodermics,  either  of  morphia,  atropia,  or 
ergotine,  in  the  neighborhood  of  the  painful  point,  may  be  continued  for 
some  time,  with  the  effect  of  diminishing  the  pain  and  the  violence  of 
the  inflammation.  Large  doses  of  iodide  of  potassium  are  of  especial  ser- 
vice ;  and  I  have  lately  recommended  inunctions  of  mercurial  ointment 
with  excellent  results.  This  latter  treatment  is  that  which  we  are  to 
employ  when  syphilis  is  suspected  ;  and  the  good  effects  are  sometimes 
seen  in  a  few  days.  As  a  dernier  ressort  nerve-section  may  be  tried  ;  but 
if  the  neuritis  has  involved  the  nerve-plexus  it  does  no  good.  It  is  only 
when  a  peripheral  nerve  is  affected  that  it  removes  the  disease. 

In  nerve-stretching — an  extremely  valuable  surgical  procedure — we 
possess  a  means  which  promises  to  be  of  great  service.  The  nerve  is 
exposed,  and  forcibly  pulled,  so  that  the  limb  shall  be  raised.  In  one 
instance  the  portion  of  the  lower  extremity,  including  the  leg  and  foot, 
was  drawn  up  by  the  sciatic,  which  had  been  bared  in  its  course  down 
the  thigh. 


542  DISEASES    OF    THE    PERIPHERAL    XERVE9. 


ANESTHESIA. 

Symptoms. — An  impairment  or  loss  of  cutaneous  or  muscular  sen- 
sibility, eitlier  localized  or  extensive,  may  be  the  result  of  central  disease, 
or  it  may  be  of  a  strictly  peripheral  nature.  It  is  of  the  latter  form 
that  I  now  propose  to  speak. 

The  anresthesia  may  imply  loss  of  the  sense  of  appreciation  of  extremes 
of  temperature,  contact,  or  painful  impressions. 

In  the  optic  nerve,  amaurosis  is  a  result,  and  with  this  there  is  com- 
monly anaesthesia  of  the  ciliary  nerve,  so  that  the  influence  of  light  pos- 
sesses no  irritant  effect.  Deafness  follows  auditory  anaesthesia,  and  loss 
of  taste,  ansesthesia  of  the  lingual  nerve. 

Anffisthesia  and  analgesia  may  exist  alone  or  in  complication,  and  we 
are  constantly  reminded  of  this  state  in  cases  where  operations  are  per- 
formed on  insensible  parts,  the  individual  only  feeling  the  power  of  trac- 
tion or  the  contact  of  the  surgical  instrument.  This  is  often  observed  in 
some  of  the  uterine  operations;  and  Dieffenbach^  alludes  to  the  anaesthetic 
condition  produced  by  some  of  the  agents  employed,  which  only  blunt 
sensibility,  while  the  sense  of  contact  still  is  preserved.  I  have  myself 
witnessed  this  phenomenon  in  patients  in  whom  local  anresthesia  had  been 
used. 

In  regard  to  the  measurement  of  sensibility,  and  its  impairment  by 
disease,  I  may  state  upon  the  authority  of  Rosenth  il,^  that  the  sensibility 
to  tickling  is  the  first  to  disappear,  then  to  contact  and  pressure,  and 
temperature,  and  finally  to  pain. 

In  cutaneous  anaesthesia  a  warm  or  cold  body  is  not  appreciable  as  such, 
but  the  individual  can  sometimes  tell  its  shape,  or  feel  the  pressure  made- 
A  lump  of  ice  is  said  to  be  irregular.  The  button  of  the  heated  cautery 
iron,  if  pressed  against  the  skin,  produces  no  discomfort,  but  only  a  sense 
of  weight.  The  loss  of  tactile  sensibility  is  generally  abolished  however, 
or  greatly  diminished.  The  patient  will  either  not  feel  the  points  of  the 
sesthesiometer  at  all,  or,  if  he  does,  will  be  unable  to  tell  how  far  they 
are  separated. 

The  local  temperature  and  vascular  supply  are  altered  in  many  cases* 
so  that  the  warmth  of  the  spot  which  has  become  anesthetic  is  a  degree 
or  two  below  that  of  the  sound  parts  adjacent.  The  vascular  alterations 
are  attended  by  blnodlessness  and  whiteness  of  the  affected  region.  This 
diminished  blood-supply  of  course  invites  pathological  alterations  of 
nutrition,  for,  when  subjected  to  influences  of  temperature  or  injury 
which  other  normal  districts  would  bear  without  damage,  the  anaesthetic 
skin  becomes  rapidly  altered.  Romberg^  alludes  to  the  occurrence  of 
blisters  and  ulcerations  which  were  readily  caused  during  cold  weather ; 

^  Der  ^ther  gegen  den  Schmerz.  1847,  p.  61. 

'  Clinical  Treatise  upon  Diseases  of  tlie  Nervous  System.    Am.  Translation,  p.  173. 

^  Manual  of  the  Nervous  Diseai^es  of  Man,  p.  202. 


ANESTHESIA.  543 

and  I  have  repeatedly  seen  the  effects  of  injurious  pressure,  of  surgical 
operations,  and  of  the  application  of  irritants.  In  one  patient  brought 
to  me  I  was  surprised  to  find  an  extensive  ulceration  of  the  skin  of  the 
forearm,  which  had  resulted  from  the  use  of  a  stimulating  liniment 
which  the  patient  had  used  with  the  idea  of  improving  an  anaBsthetic 
state  dependent  upon  rheumatism. 

Ancesthesla  of  the  Fifth  Pair. — This  form  of  anaesthesia  is  commonly 
of  peripheral  origin,  and  of  thirty-five  cases  collected  by  Ortel-Ebrard^  it 
resulted  but  nine  times  from  intracranial  tumors.  It  is  of  spontaneous 
origin  usually;  and  the  upper  branch  is  most  profoundly  affected,  so  that 
the  loss  of  sensibility  is  limited  to  the  brow  and  region  about  the  eye,  by 
anaesthesia  of  the  cornea,  and  consequent  nutritive  changes  in  that  part 
of  the  optical  apparatus.  A  case  of  this  kind  was  reported  by  Dr.  H  D. 
Noyes,^  of  New  York,  in  which  there  was  very  decided  sloughing  of  the 
cornea.  The  phenomena  following  anaesthesia  of  this  nerve  may  be  thus 
tabulated  : — 

C  Anaesthesia  of  upper  eyelid 
Involvement  of  ophthalmic  branch.  s      and  forehead.     Irritating 

C     substances  are  not  felt. 

f  Anaesthesia  of  middle  por- 
Involveraent  of  superior  maxillary  branch.  I      tion  of  face.  Insensibility 

(.      of  gums  of  upper  jaw. 

(  Anaesthesia  of  skin  of  lower 

I  portion  of  face ;  increa-ed 
Involvement  of  inferior  maxillary  branch.  ;      flowof  saliva;  mastication 

I       difficult ;    gums  of  lower 

l,^     jaw  insensible. 

The  patient  sometimes  finds  that  the  edge  of  the  tumbler  or  vessel  from 
which  he  drinks  occasionally  feels  as  if  it  were  broken.  Several  of  these 
cases  are  reported  by  Bell.^  In  one  of  my  cases  the  patient  could  not 
spit  in  a  straight  line,  while  the  secretion  of  saliva  was  quite  abundant. 
This  same  patient  complained  that  his  gums  were  insensitive.  These 
peculiar  buccal  and  labial  symptoms  are  generally  early  and  prominent 
expressions.  Sense  of  smell  and  sensibility  of  the  nostrils  and  torgue  are 
lost  when  other  branches  are  affected.  A  kind  of  anaesthesia,  alluded  to 
by  Besuier,  Rendu  and  others  is  that  depsndent  upon  venereal  excesses 
and  the  pathological  state  is  probably  a  lively  spinal  congestion.  In  a 
case  reported  by  Besnier,  there  was  some  slight  paresis  of  the  lower  ex- 
tremities with  analgesia,  and  pronounced  loss  of  tactile  sensibility.  The 
patient  was  able  to  perceive  temperature  fluctuations.  A  cure  fullowed 
six  weeks  of  energetic  treatment. 


Paralypie  du  Trijemeau,  These  Paris,  1867. 

N.  Y.  Medical  Journal,  1871- 

The  Nervous  System,  etc.,  3J  ed.,  p.  338,  et  seq. 


544  DISEASES     OF    THE    PERIPHERAL    NERVES. 

"When  the  radial  nerve  is  the  seat  of  the  peripheral  trouble,  it  will  be 
found  that  the  back  of  the  hand  retains  its  sensibility.  The  lower  ex- 
tremities may  be  affected  when  the  condition  is  the  result  of  pressure 
made  upon  the  sciatic,  and  in  the  case  of  several  skin-diseases  the  loss  of 
sensibility  may  be  general.  Leprosy,  syphilitic  alopecia,  and  other  skin- 
diseases  may  all  be  attended  by  loss  of  cutaneous  sensation,  which  is  the 
result  of  local  dermal  alteration  of  function.  Bulkley^  has  very  ably 
considered  this  subject. 

In  this  connection  it  will  not  be  amiss  to  refer  to  a  form  of  ansesthesia, 
called  by  Raynaud  "  asphyxie  locale  des  extremities"  which  is  commonly 
described  as  a  vaso  motor  disorder.  Nine  years  ago  I  presented  cases, 
and  Dr.  M'Bride  has  since  discussed  the  subject  in  a  paper  read  before 
the  Neurological  Society.  Through  contraction  of  the  arterioles,  the 
fingers  become  pale,  and  there  is  a  sharply  defined  local  syncope.  The 
fingers  are  anaesthetic,  and  the  sense  of  appreciation  of  temperature  is 
lost.  The  arterial  contraction  may  be  the  consequence  of  a  temporary 
spasm,  or  it  may  have  a  grave  permanency,  and  be  followed  by  gan- 
grene. The  cases  I  have  seen  have  been  of  short  duration,  and  the 
subjects  were  women.  The  local  syncope  and  ansesthesia  is  generally 
bilateral. 

The  ansesthesia  often  remaining  after  diphtheria  is  one  of  considerable 
interest.  It  may,  or  not,  be  associated  with  paresis,  but  in  either  case 
the  velum  palati  is  commonly  affected,  and  in  many  patients  other 
parts  of  the  body  become  anaesthetic.  See^  reports  an  example  in  which 
the  entire  surface  of  the  body  was  insensitive,  the  plantar  surfaces  even 
being  affected,  and,  as  a  consequence,  there  was  iuco-ordination.  This 
suggests  the  query  whether  the  cases  reported  as  locomotor  ataxia  of  diph- 
theritic origin  were  not,  after  all,  examples  of  plantar  ansesthesia. 

Causes. — Cutaneous  ansesthesia  may  be  due  to  pressure  made  upon, 
a  nerve-trunk  in  its  course,  or  to  the  compression  of  peripheral  areas  of 
greater  or  less  extent,  or  to  local  impairment  of  function  by  exposure  to 
cold,  to  certain  chemicals,  or  to  like  agents  ;  while  general  diseases,  such 
as  syphilis  or  rheumatism,  by  local  disease  and  infiltration,  greatly  alter 
the  function  of  cutaneous  nerve-filaments.  The  toxic  eSects  of  lead 
shown  in  abolition  of  cutaneous  sensibility  were  pointed  out  by  Beau  ^  in 
1848.  In  38  cases  analyzed  by  him,  loss  of  tactile  sensibility  was  de- 
tected not  only  in  skin  of  the  forearm  and  arm,  but  in  parts  lined  with 
mucous  membrane,  the  pharynx  and  the  interior  of  the  nose.  Intense 
cold,  liniments  which  contain  aconite,  or  long  immersion  of  the  hands  in 
fluid  of  any  kind,  will  result  in  a  loss  of  sensibility.  One  of  my  patients 
was  a  dyer,  whose  hands  were  kept  in  warm  dye-liquids  for  many  hours  ; 
and  some  of  the  French  writers  give  examples  of  the  disease  among 

1  The  Relations  of  the  Nervous  System  to  Diseases  of  the  Skin.  Archiv.  of  Elect, 
and  Neurology,  1874—5. 

2  Gaz  Med."  de  Paris,  1664. 

'  R^cherches  sur  I'anesthesie,  Archives.  Gen.  de  Med.,  1848. 


ANAESTHESIA.  545 

washerwomen.  Alkaline  fluids  are  more  favorable  to  its  production  than 
any  others.  Tight  splints,  blows ;  diphtheria  and  other  acute  maladies, 
hysteria,  and  several  other  conditions  play  a  part  in  its  etiology. 

Diagnosis. — Peripheral  anaesthesia  must  be  diagnosed  from  the  cen- 
tral condition,  and  it  is  necessary  that  we  should  bear  in  mind  not  only 
the  anatomical  arrangement  of  the  nervous  supply,  but  the  coexistence  or 
absence  of  symptoms  of  central  disturbance.  Among  the  latter  are  loss 
of  power,  which  usually  accompanies  the  ansesthesia,  or  one  or  more  of 
the  many  symptoms  previously  alluded  to. 

Trigeminal  an?esthesia  is,  perhaps,  more  difiicult  to  trace  out  than  that 
of  other  nerves.  Romberg^  thus  enumerates  the  indications  of  anaesthesia 
of  peripheral  or  central  origin  : — 

"  a.  The  more  the  anaesthesia  is  confined  to  single  filaments  of  the 
trigeminus,  the  more  peripheral  the  seat  of  the  cause  will  be  found  to 
be. 

"  h.  If  the  loss  of  sensation  afiects  a  portion  of  the  facial  surface,  to- 
gether with  the  corresponding  facial  cavity,  the  disease  may  be  assumed 
to  involve  the  sensory  fibres  of  the  fifth  pair  before  they  separate  to  be 
distributed  to  their  respective  destinations ;  in  other  words,  a  main 
division  must  be  afiected  before  or  after  its  passage  through  the  cranium. 

"  c.  When  the  entire  sensory  tract  of  the  fifth  nerve  has  lost  its  power, 
and  there  are  at  the  same  time  derangements  of  the  nutritive  functions  in 
the  affected  parts,  the  Gasserian  ganglion,  or  the  nerve  in  its  immediate 
vicinity,  is  the  seat  of  the  disease. 

"  d.  If  the  anassthesia  of  the  fifth  nerve  is  complicated  with  disturbed 
functions  of  adjoining  cerebral  nerves,  it  may  be  assumed  that  the  cause 
is  seated  at  the  base  of  the  brain." 

Prognosis. — It  is  by  no  means  bad  after  the  cause  is  removed. 
Anaesthesia  from  pressure  is  rapidly  restored,  provided  the  mechanical 
injury  be  not  too  great.  If  there  be  division  of  the  nerve,  the  process  of 
reparation,  which  rarely  extends  for  more  than  a  few  months,  is  followed 
by  a  healthy  return.  With  syphilis  and  metallic  poisoning,  and  skin  dis- 
eases the  case  is  different. 

Treatment. — Electricity  offers  the  best  mode  of  relief.  The  wire 
brush  and  faradic  current  are  to  be  employed  every  day  ;  and  at  the  same 
time  applications  of  alternate  heat  and  cold,  friction  and  massage,  are 
useful  adjuvants. 

1  Eomberg.  A  Manual  of  the  Nervous  Diseases  of  Man.  Sydenham  trans.,  vol. 
i.  p.  213,  etseq. 

35 


646  DISEASES    OF    THE    PERIPHERAL    NERVES. 


TUMORS  OF  NERVES. 

Synonym. — Neurorn  ata. 

A  uerve  may  be  the  seat  of  either  a  syphilitic,  cancerous,  sarcomatous, 
myxomatous,  or  other  growth  which  may  involve  or  destroy  some  point 
in  its  continuity,  or  form  as  a  benignant  tumor  at  its  point  of  severance. 

Very  little  has  been  written  on  this  important  subject ;  but  among  the 
most  valuable  contributions  to  the  literature  of  nerve-tumors  is  an  excel- 
lent thesis  by  Foucalt,^  and  various  scattered  articles  by  VerneuU,*  Le 
Fort,  Axenfeld,  Roger,  and  others. 

Nerve-tumors  may  be  classified  as  neuromata  (nervous  neuroma  of  We- 
ber) and  medullary  nerve-tumors,  which  involve  the  nervous  structure 
itself ;  and  pseudo-neuromata,  which  include  the  fibromata,  myxomata, 
epithelioma,  as  well  as  cysts  and  tumors  of  a  like  character. 

Medullary  or  ganglion  tumors  are  quite  rare,  and  are  of  a  hyperplastic 
character.  Lebert  ^  described  a  neuroma  of  the  superior  cervical  ganglion, 
in  which  all  traces  of  true  nervous  matter  had  disappeared,  and  naught 
remained  but  a  fibro-fatty  structure.  Rjbin*  has  found  a  neuroma  in  the 
solar  plexus,  and  Virchow  has  also  brought  forward  examples. 

Neuroma  of  nervous  fasciculi  {nevromes  fascicules)  include  the  little 
painful  tumors  which  are  met  with  after  amputation,  which  give  rise  to 
stump  neuralgia,  and  attain  the  size  often  of  a  hazel-nut.  Dtipuytren,* 
Cornil*  and  Ranvier,  Axmann'  and  Weissmau,*  have  all  described  their 
appearance  and  structure,  which  is  fibrous  and  hard,  and  the  nerve  tubes 
are  tortuous  and  interlacedi 

The  pseudo-neuromata  are  of  many  varieties.  They  are  developed 
usually  in  the  course  of  the  nerve,  and  the  neurilemma  is  thickened,  and 
should  the  nerve  be  cut  across,  a  white  or  yellowish  hardening  will  be 
presented.  Should  the  tumor  be  fibrous,  the  peculiar  microscopical  ap- 
pearance may  be  observed.  Fibromata  rarely  exceed  the  size  of  an 
almond ;  but  when  there  is  any  fluid  found,  as  in  the  case  of  fibro-cystic 
tumors,  the  volume  of  the  enlargement  may  be  much  greater. 

The  accompanying  cut  represents  a  sarcoma  of  the  ulnar  nerve,  and 
was  observed  by  Demarquay  at  the  Maison  Municipale  de  Sante. 

Nerve-tumors  prefer  the  nerves  of  the  upper  and  lower  extremities,  and 
in  the  leg  the  posterior  tibial  nerve  seems  to  be  a  common  site.  It  is  not 
uncommon  to  find  a  great  many  tumors  of  this  kind  existing  at  the  same 
time.      In  one  case  reported  by  Foucault,  1400  of  them  were  f  luiid,  but 

1  Siir  les  Tumeurs  des  Nerves  Mixtes,  Thess  de  Paris,  1872. 

*  Arch,  de  MeJ.,  tome  xviii.  1S61. 

3  Mem.  de  la  Soc.  de  Clin.  1853,  3  fasc. 

*  Comptea  Eendus  de  la  Soc.  de  Biol.,  1854. 
'•  Loc.  cit. 

«  Memoiresde  la  Soc.  Biologie,  t.  v.,  3d  s^rie,  1863. 

7  Beitrage  ziir.  mikr.  Anat.  da  Ganglion  Nervensystems,  Berlin,  1853. 

*  Ueber  Nerveanenbildung  (Zaitschr.  f.  Rationalie  Med.  1859.) 


TUMORS    OF    NERVES, 


547 


Fig.  69. 


this  is  exceptional,  and  it  is  probable  that  multiple  neuromata  are  more 
frequeatly  found  in  patients  who  are  of  the  cancerous,  syphilitic,  or  some 
other  diathesis.  Very  often  these  growths,  the  result  of  injury,  are  sub- 
cutaneous. In  one  of  my  cases  the  growth  was  found  at  the  elbow  at  the 
exposed  site  of  the  ulnar  nerve,  and  its  origin  followed  a  blow  upon  that 
part. 

Pain,  as  I  have  said,  is  the  prominent  symptom  of  such  growths.  This 
pain  may  appear  upon  the  tumor,  but  usually  follows  its 
establishment.  It  may  be  localized  or  diffused,  or  may 
be  provoked  by  pressure  on  the  spot  or  spots  which  mark 
the  site  of  the  growth  ;  for,  when  the  tumors  are  multi- 
ple, of  course  the  sensory  troubles  are  equally  numerous. 
The  pain  may  radiate  from  the  tumor,  or  may  dart  down 
or  up  the  affected  nerve.  It  is  not  so  intense  with  fibro- 
mata, syphilomata,  or  sarcomata,  or  when  the  tumor  is 
composed  mainly  of  true  nervous  tissue,  as  is  the  case  in 
stump  growths,  and  in  these  examples  it  is  productive  of 
severe  neuralgia  of  a  reflex  character.  Spasms,  perma- 
nent muscular  contractions,  and  sometimes  a  peculiar  con- 
striction of  the  thorax  of  a  tetanic  nature,  with  epilepti- 
form seizure  and  centripetal  pain,  are  indicative  of  certain 
reflex  disturbances. 

Treatment. — Operation  seems  to  offer  the  only  hope 
of  relief,  and  in  stump  neuromata  re-amputation  is  often- 
times necessary.  It  will  be  found  necessary  to  deeply 
auce^thetize  the  patient,  as  the  sensibility  is  so  morbidly 
active  that  ordinary  anaesthesia  is  insufficient.  The  re- 
moval of  a  considerable  piece  of  the  nerve  is  advisable, 
for  it  is  not  rare  to  find  considerable  infiltration  or  deposit 
in  its  substance  for  some  distance  from  the  actual  growth. 
In  syphilis,  mercurials  and  the  iodides  offer  some  show 
of  relief,  and  these  are  the  only  remedies  when  the 
growth  is  deep-seated.  Legrand  ^  and  others  have  recom- 
mended caustic  applications  in  superficial  regions,  and 
Sii-b  )ld  ph-e  removed  a  tumor  in  this  way  from  the  an- 
terior tibial  nerve.  The  operation  is  rather  severe,  and  is  attended  with 
doubtful  success. 


Sarcomatous      Nen- 
roma.     (Foucalt ) 


^  Gaz.  Med.,  Compte-Rendus  de  I'Acad.  des  Sciences,  1858. 


548  DISEASES    OF    THE    PERIPHERAL    NERVES. 


CHAPTEK    XVIII. 

DISEASES  OF  THE  PERIPHERAL  NERVES  (Continued). 
LOCAL   PARALYSES. 

FACIAL  PARALYSIS. 

Synonyms. — Bell's  paralysis ;  Histrionic  paralysis. 

Facial  paralysis  may  be  either  double  or  single,  but  is  more  often  the 
latter  ;  aud  it  may  depend  upon  a  lesion  of  a  peripheral  kind,  or  one  that 
may  be  seated  in  the  temporal  bone,  or  at  any  point  in  its  course  within 
the  cranial  cavity,  or  else  at  its  origin. 

The  bilateral  form  is  rare,  and  is  always  the  result  of  a  central  lesion ; 
but  the  peripheral  form  is  unilateral,  and  is  a  very  common  affection. 

Symptoms. — The  patient,  after  exposure,  may  suddenly  be  attacked  ; 
and  the  first  intimation  he  generally  basis  in  the  morning,  when  he  arises. 
He  then  finds  his  face  to  be  all  awry,  and  his  appearance  is  absurd  to  the 
last  degree;  one  side  being  drawn  up,  while  the  other  is  immobile,  as  the 
muscles  of  expression  are  powerless.  If  he  laughs,  the  contortion  is  more 
marked,  and  if  he  attempts  to  whistle  he  will  find  that  he  is  utterly  una- 
ble to  do  so.  The  corner  of  the  mouth  on  the  sound  side  is  drawn  up, 
and  the  furrow  at  the  angle  of  the  nose  is  more  marked  than  natural. 
The  opposite  side  of  the  face  is  smooth ;  and,  in  the  passive  state,  the 
muscles  seem  to  sag  heavily  downwards.  It  is  impossible  for  him  to  cor- 
rugate his  eyebrows  ;  aud  the  eyelids  of  the  paralyzed  side  cannot  be 
closed,  so  that  dust  and  foreign  substances  collect,  producing  irritation 
and  discomfort.  This  is  due  to  the  paralysis  of  the  orbicularis,  and  at 
the  same  time  the  levator  palpebrarum  contracts  and  keeps  the  eyeball 
exposed.  The  individual  is  unable  to  blow  out  a  candle,  and  articulation 
is  interfered  with  to  a  slight  degree.  Should  he  be  an  old  man,  any 
wrinkles  or  furrows  that  may  have  existed  on  the  paralyzed  side  are  ef- 
fectually effaced,  and  give  that  part  a  most  ghastly  appearance.  Consid- 
erable discomfort  results  from  the  insufficiency  of  the  lower  lid,  so  that  the 
tears,  instead  of  being  conducted  to  the  lachrymal  canal,  find  their  way 
over  the  cheek. 

If  the  lesion  be  situated  within  the  temporal  bone  or  the  cranium,  a 
much  more  extensive  paralysis  may  result.  This  is  indicated  by  a  loss  of 
power  of  the  muscles  of  the  palate,  uvula,  and  other  parts  of  the  fauces. 

When  the  patient  opens  his  mouth,  the  palatine  arch  will  be  found  to 
be  altered,  the  anterior  pillars  of  the  fauces  being  shorter,  so  that  one  side 


FACIAL    PARALYSIS.  549 

falls  lower  than  the  other,^  The  uvula  will  also  be  found  to  be  arched, 
the  concavity  looking  towards  the  sound  side.  The  tongue  will  then  also 
be  paralyzed,  so  that  its  surface  is  smooth  ;  and  there  may  be  a  dryness  of 
the  mouth,  which  results  from  diminished  secretion  of  saliva.  Should  the 
portio  mollis  be  affected,  there  may  be,  in  addition,  deafness.  If  the 
third  nerve  be  affected,  as  it  sometimes  is,  of  course  ptosis  with  dilated 
pupil  and  paralysis  of  the  recti  will  result. 

Roux,^  who  was  paralyzed  in  this  manner,  perceived  a  metallic  taste  in 
the  right  side  of  the  tongue. 

Should  the  paralysis  be  bilateral,  the  patient's  features  will  denote  an 
entire  lack  of  exprtssion,  and  there  is  not  the  slightest  evidence  of  any 
emotional  excitement  expressed,  even  should  the  patient  be  agitated  by  the 
most  intense  pleasure  or  the  deepest  grief.  The  muscles  are  flabby,  and 
the  face  seems  more  like  a  mask  than  what  it  really  is  ;  and,  as  is  the  case 
in  advanced  progressive  muscular  atrophy,  the  only  animated  features  are 
the  eyes. 

Romberg^  describes  the  appearance  of  a  patient  in  these  words:  "  In.a 
girl  of  16,  in  Dupuytren's  Clinique,  who  was  affected  with  bilateral  para- 
lysis, there  was  no  distortion,  but  a  pendulousness  and  entire  absence  of 
motion  was  perceptible  in  all  the  features.  The  eyelids  only  closed  half, 
the  lips  stood  apart,  and  played  backwards  and  forwards  from  the  impulse 
of  respiration.  The  expressive  countenance  bore  a  serious  character,  which 
contrasted  forcibly  with  the  patient's  frame  of  mind.  She  was  heard  to 
laugh  aloud,  but  the  laugh  appeared  to  come  from  behind  a  mask."  Sensa- 
tion is  not  usually  impaired. 

Causes. — The  peripheral  form  of  paralysis  may  follow  exposure  to 
cold,  rheumatic  exudation,  and  injuries  of  various  kinds.  A  cause  which 
is  frequently  observed  is  the  chilling  of  the  face  by  a  blast  of  cold  wind ; 
and  the  frequency  of  this  cause  has  led  to  the  adoption  by  the  French 
writers  of  the  term,  "  Coup  de  vent."  I  have  met  with  many  cases  in 
which  the  paralysis  took  place  after  a  railroad  journey,  the  individual  hav- 
ing sat  by  an  open  window. 

In  one  instance  the  patient,  who  was  a  young  lady,  had  been  dancing 
violently,  and  had  afterwards  gone  into  a  damjD  conservatory  to  cool  off; 
the  palsy  was  shortly  afterwards  noticed. 

Rheumatic  exudations  may  produce  pressure  upon  some  of  the  nerve- 
twigs,  or  an  attack  of  parotitis  may  result  in  pressure  upon  the  cervico- 


^  Hughlings  Jackson  (London  Lancet,  Jan.  16,  1875)  does  not  consider  that  devia- 
tion of  the  palate  occurs  in  uncomplicated  disease  of  the  portio  dura,  and  he  does  not 
believe  deviation  of  the  uvula  to  be  uncommon  in  healthy  people.  Troltsch  says  that 
the  levator  palati  is  supplied  by  the  vagus,  which  explains  the  phenomena  witnessed 
by  Jackson,  viz.,  marked  palsy  of  one  side  of  the  palate,  with  palsy  of  the  vocal 
cord  on  the  same  side,  as  a  result  of  intracranial  disease.  This  case,  however,  is  ex- 
ceptional. 

2  Descot.     Diss,  sur  les  Affections  locales  desNerfs,  Paris,  1825,  p.  331. 

^  Op.  cit.,  vol.  ii.  p.  268. 


550  DISEASES    OF    THE    PERIPHERAL    NERVES. 

facial  branch.  Injuries  of  the  nerve,  whether  such  as  follow  coarse  trau- 
matism or  accidental  section  of  the  nerve  during  a  surgical  operation,  are 
sometimes  the  cause  of  the  paralysis. 

Weir  Mitchell  relates  several  cases  of  this  kind.  Three  of  these 
(Cases  61,  62,  and  63)  followed  gunshot  wounds.^  In  one  the  portio  dura 
of  the  left  side  was  injured,  and  as  a  consequence  there  were  facial  palsy, 
impaired  speech,  and  loss  of  gustation.  Hearing  was  impaired  from 
shock  transmitted  to  the  auditory  nerve.  Sir  Charles  Bell'  divided  the 
facial  in  removing  a  tumor,  and  other  cases  are  reported  by  various  sur- 
geons. 

Carious  disease,  as  well  as  fractures  of  the  temporal  bone,  often  produces 
paralysis,  either  by  pressure,  by  the  products  of  inflammation,  or  by  di- 
rect contusion. 

Tumors  and  various  aural  growths  are  occasionally  causes  of  this  second 
form  of  facial  palsy;  and  Romberg^  reports  a  case,  seen  by  Henle,  in  which 
a  tuberculous  deposit  was  found  beneath  the  middle  lobe  of  the  brain, 
with  destruction  of  the  petrous  portion  of  the  temporal  bone  ;  and  Fro- 
riep*  also  found  a  deposit  of  tuberculous  matter  in  the  Fallopian  canal, 
with  caries  of  the  petrous  portion  of  the  bone. 

Degeneration,  exudation,  and  tumor  in  or  near  the  pons  may  also  be  the 
cause  of  the  deep  form. 

The  following  case  is  an  example  of  deep-seated  paralysis,  evidently 
dependent  upon  aural  disease : — 

Samuel  M.,  aged  27 ;  United  States,  canal  boatman ;  came  to  me  July 
3,  1876.  Three  days  before  the  first  visit,  after  exposure  while  washing 
the  decks  of  his  boat,  he  became  paralyzed.  He  had  had  earache  before 
for  several  days,  but  did  not  consider  it  of  sufficient  moment  to  quit  work; 
and  his  first  intimation  of  trouble  was  the  discomfort  produced  by  parti- 
cles of  dust  which  blew  in  his  eye.  He  could  not  close  his  left  eye,  and 
on  looking  in  the  glass  he  discovered  the  paralysis.  There  was  no  pain, 
nor  any  subjective  sensation  of  any  kind.  He  found  that  he  could  not 
laugh,  nor  blow  his  nose,  and  when  he  attempted  the  latter  "  the  wind 
came  out  of  his  mouth."  AVhen  I  saw  him  there  was  paralysis  of  both 
branches  of  the  seventh  nerve.  Hearing  was  very  imperfect,  and  he  could 
not  count  the  ticks  when  the  watch  was  pressed  to  the  left  ear.  The  left 
palatine  arch  was  obliterated,  and  he  could  not  fully  protrude  the  tongue, 
which  was  quite  dry.  The  left  side  of  the  face  is  quite  flat,  and  the  mus- 
cles of  the  other  side  act  to  such  a  degree  as  to  draw  up  the  right  corner 
of  the  mouth,  producing  the  characteristic  deformity.  When  he  opens 
his  mouth  the  orifice  is  unsymmetrical.  He  cannot  whistle  or  expecto- 
rate, he  cannot  close  the  left  eye,  but  when  he  attempts  to  do  so  the  hall 
is  drawn  upwards,  so  that  the  sclerotic  is  shown  to  a  great  extent.  Con- 
tractility to  both  currents  fair  ;  mediate  and  immediate  galvanization  are 
followed  by  muscular  response.     He  has  some  earache.     When  the  elec- 

1  Injuries  of  Nerves,  etc.,  p.  392,  et  seq. 

2  The  Nervous  Sy.stera  of  the  Human  Body,  3d  ed.,  1836,  p.  56. 

*  Romberg,  op.  cit.,  p.  272. 

*  Massalien,  Diss.  Inaugur.  de  Nervo  Faciali,  Berolini,  1836. 


FACIAL    PARALYSIS.  551 

trode  is  passed  over  the  superficial  points  of  the  fifth,  there  is  decided 
pain,  no  anaesthesia;  force  of  masseter  muscles  tested  by  putting  the  dyna- 
mometer bulb  between  the  teeth  and  interposing  two  pieces  of  wood  ;  no 
loss  of  power  as  compared  with  my  own  attempts.  Tympanum  congested  ; 
and  I  infer  that  there  is  middle  ear  disease.  R.  Potass,  iodid.  and  syring- 
ing ear  with  warm  water. 

July  6.  Has  had  intense  pain  in  the  left  ear,  throbbing  and  pains  which 
radiate  over  the  head.  Pressure  over  mastoid  process  gives  great  distress, 
as  does  electrization.     Leeching  to  inner  tragus. 

9th.  Says  that  there  was  a  discharge  of  pus  last  night.  After  syringing 
out  1  find  a  perforated  tympanum.  Stopped  iodide,  and  ordered  syring- 
ing with  ^^•arm  water  and  glycerin. 

ISth.  Discharge  from  ear  much  less.  Used  iodoform  powder  locally. 
Muscles  do  not  respond  so  well  to  eiiher  current.     Iodide  renewed. 

nth.  iSo  response  to  current.     Faradized  nevertheless. 

ly^A,  2ld,  2od,  27th.  Used  iodoform.  Aural  disease  almost  well,  but 
patient  still  deaf.     Muscles  still  inactive. 

30//i.  Tested  sense  of  taste,  and  find  it  markedly  afl^ected  ;  his  tongue 
seems  quite  smooth.  He  has  had  from  the  first  some  clumsiness  in 
speech. 

Oct.  1877.  There  has  been  very  slight  improvement  since  the  last  entry. 
The  facial  deformity  is  not  so  great.  He  is  still  deaf.  His  speech  is  clear, 
but  he  cannot  whistle  as  yet.  The  muscles  do  not  respond  to  the  currents. 
He  suffers  great  annoyance  from  the  accumulation  of  saliva,  and  when  he 
expectorates  he  soils  his  clothing. 

Pathology. — The  anatomical  distribution  of  the  facial  nerve,  and  its 
connection  with  other  nerves  may  be  referred  to  in  illustration  of  the  pa- 
thology of  the  affection.  Beginning  externally,  we  find  that  the  facial 
nerve  supplies  the  muscles  of  the  face,  the  malar  branches  innervating  the 
orbicular  muscles  of  the  eyes  ;  that  the  infra-orbital  supply  the  buccina- 
tor and  orbicularis  muscles,  and  the  levator  labii  superioris  alceque  nasi 
muscles;  while  the  eervico-facial  division  of  the  nerve  passes  through  the 
parotid  gland,  and  supplies  the  muscles  of  the  mouth  and  lower  jaw; 
consequently  a  lesion  of  any  of  these  branches,  or  of  the  main  trunk  at  its 
exit  from  the  stylo-mastoid  foramen  would  be  followed  simply  by  paresis 
of  the  facial  muscles.  Should  the  lesion  take  place  in  the  aqueductus 
Fallopii,  or  behind  the  geniculate  ganglion,  we  would  find  as  a  conse- 
quence paralysis  of  the  muscles  of  the  face,  the  tongue,  through  paralysis 
of  the  chorda  tympani,  and  paralysis  of  the  palate  muscles,  through  para- 
lysis of  the  larger  superficial  petrosal  nerve,  which  runs  from  the  genicu- 
late ganglion  to  the  spheno-palatine  ganglion.  Deep  lesions  may  involve 
the  third  nerve,  and  perhaps  the  sixth.  The  lesions  and  their  results  may 
be  thus  arranged :— 


552  DISEASES    OP    THE    PERIPHERAL    NERVES. 

Paralysis  of  the  Seventh  Nerve. 

EXTERNAL  THIRD.         MIDDLE  THIRD.  INTERNAL  THIRD. 

Facial  Branches.  Petrostal  nerves,  Auditory        Possibly  lesion    involve 

(Portio  mollis),  Chorda      the  3rd  and  Gth  nerves,  and 

Paralysis  of  the  Tympani.                   then  besides  all  of  the  fare- 

Orbicuiaris   palpebrarum,  going  there  may  be  paraly- 

Corrugator  supercilii,  Paralysis  of  all  the  fore-     sis  of  the  levator  palpebrae 

Levator  iabii,  etc.,  going  as  well  as  lingnalis,     and  the  recti  muicles. 

Pyramidalis  nasi,  tensor   and    laxator    tym- 

Diagastric,  pani,    levator   palati,    and 

Buccinator,  azygos  uvulffi. 

Orbicularis  oris, 

Depressor  anguli  oris,  I 

Levator  Iabii  inf. 

Diagnosis. — The  appearance  of  facial  paralysis  may  be  a  source  of 
alarm  to  the  individual,  who  is  ready  to  believe  it  a  feature  of  cerebral 
hemorrhage  or  deep  organic  trouble.  It  is  much  more  profound,  however, 
than  the  form  which  accompanies  cerebral  hemorrhage ;  and  generally 
there  is  hemiplegia  of  the  extremities  in  the  latter  disease.  In  this  form 
it  is  impossible  for  the  patient  to  shut  the  affected  eye,  while  in  the  other 
disease  there  is  usually  no  difficulty  in  so  doing.  Sensation  is  also  affected 
in  the  paralysis  from  cerebral  hemorrhage,  and  it  is  not  unusual  to  find 
ptosis.  The  matter  of  importance,  however,  is  the  diagnosis  of  the 
variety  of  facial  palsy,  superficial  or  deep :  and  we  may  avail  ourselves 
of  electricity  in  settling  this  point. 

If  the  paralysis  be  peripheral,  the  muscles  retain  their  contractility 
for  several  weeks.  If,  on  the  contrary,  the  lesion  be  central,  or  in  a 
nerve-trunk,  they  lose  their  power  of  response  to  a  faradic  current  in  a 
few  days,  and  later  to  even  a  galvanic  current,  and  the  muscles  finally 
become  atrophied.  If  the  paralysis  be  due  to  bulbar  disease,  the  appear- 
ance of  symptoms  indicating  impairment  of  other  nerves  and  an  eventful 
fatal  termination  should  settle  the  nature  of  the  affection,  and  enable  us 
to  make  a  prognosis.  The  existence  of  carious  disease  and  its  indica- 
tions, the  complication  of  deafness,  and  the  co-existence  of  indications  of 
deep  trouble,  should  be  all  taken  into  account. 

Prog"nosis. — The  prognosis  of  the  peripheral  form  of  the  disease  is 
very  good,  and  under  proper  treatment  the  paralyzed  muscles  may  be 
rapidly  restored.  There  is  generally  early  loss  of  muscular  contractility, 
which  only  the  galvanic  current  can  restore.  If  there  is  no  response  to 
electrical  excitement,  and  the  muscles  of  the  paralyzed  side  are  wasted 
and  contracted,  there  is  little  to  be  hoped  for.  I  consider  that  more  de- 
pends upon  the  early  adoption  of  electrical  treatment  than  anything  else  ; 
and  if  there  be  a  delay  in  the  selection  of  remedies,  and  in  the  attempts 
to  restore  the  muscles  by  mechanical  support  and  electricity,  the  progno- 
sis, which  may  have  been  favorable  in  the  beginning,  becomes  less  and 
less  so,  the  longer  action  is  delayed. 


FACIAL    PARALYSIS.  553 

Syphilis  is  a  favorable  element  if  tlie  paralysis  be  due  to  deep  lesions ; 
but,  if  it  be  caused  by  brain-tumors,  exudations,  or  degeneration,  there  is 
scarcely  any  hope. 

Treatment. — It  is  necessary  in  this  disease  to  direct  the  treatment 
not  only  to  the  cause,  when  one  can  be  found,  but  also  to  the  restoration 
of  the  paralyzed  muscles. 

Should  rheumatism  exist,  we  are  to  employ  colchicum  and  iodide  of 
potassium ;  if  syphilis,  the  specifics  which  are  at  our  disposal ;  and  if 
there  be  caries,  we  are  to  improve  the  patient's  general  health  by  nour- 
ishment and  stimulants,  and  to  apply  such  local  treatment  as  may  seem 
proper.  The  medicaments  which  will  be  found  to  be  of  service  for  the 
direct  treatment  of  the  paralysis  are  strychnia,  iron,  and  quinine.  Elec- 
tricity is  of  great  service ;  and  we  may  begin  with  the  galvanic  current 
and  use  the  faradic  as  soon  as  it  can  produce  contractions.  The  negative 
pole  of  the  galvanic  battery  should  be  placed  behind  the  ear,  and  the 
positive  pole  passed  over  the  different  facial  muscles.  The  glass  "  bain 
electrique  "  should  be  applied  to  the  eye,  so  that  the  orbicularis  shall  be 
brought  under  the  influence  of  the  current. 

The  mechanical  treatment  of  facial  paralysis  has  been  advocated  by 
Detmold,  and  with  admirable  results.  A  piece  of  tin  wire  is  bent  at  both 
ends  (Fig.  70),  and  one  end  is  passed  over  the  ear  and  the  other  hooked 
in  the  angle  of  the  mouth,  so  that  the  muscles  of  the  paralyzed  side  shall 
be  supported.  In  several  of  Detmold's  cases  it  was  found  to  work  ex- 
ceedingly well. 

Fig.  70. 


Wire  Hook  for  the  Treatment  of  Facial  Paralysis. 

This  apparatus  may  be  worn  at  night  or  during  the  day,  and  does  not 
give  the  patient  any  discomfort  whatever. 

Dr.  Van  Bibber  has  suggested,  in  the  treatment  of  ptosis,  the  use  of  a 
small  strip  of  court  plaster,  which  is  afBxed  to  the  upper  lid  and  to  the 
forehead  above. 

I  may  append  a  case  of  facial  palsy  of  a  syphilitic  nature  cured  by 
electricity  in  a  remarkably  short  space  of  time. 

W.  O.  I.,  30  years  ;  United  States,  boatman.  Previous  history :  He 
has  never  been  seriously  ill,  but  ten  vears  ago  he  had  a  chancre,  followed 
by  marked  secondary  symptoms.  The  only  other  ailment  was  a  severe 
attack  of  rheumatism,  occurring  a  year  before.  This  was  undoubtedly  a 
secondary  symptom.     His  present  difficulty  began  three  months  ago.     At 


554  DISEASES    OF    THE    PERIPHERAL    NERVES. 

night  he  was  disturbed  by  intense  cephalic  pains,  dizziness,  and  disordered 
virion.  For  several  days  the  pains  were  steady  and  most  violent  under 
either  temple  ;  he  was  also  annoyed  by  post-aural  pains.  He  then  found 
that  his  hearing  was  becoming  less  acute,  till  the  lesion  finally  occurred. 
This  took  place  toward  the  latter  part  of  July.  1880.  He  awoke  in  the 
morning  and  felt  a  pain  in  the  head,  attended  by  swelling  and  putfiness  in 
the  face.  His  attention  was  called  by  several  of  his  associates  to  the 
"  crookedness"  of  his  face.  He  looked  in  the  gla^s,  and  saw  the  drooping 
of  the  left  side  of  the  face,  with  complete  paralysis  of  the  muscles  at  the 
corner  of  the  miuth  ;  then  followed  total  loss  of  hearing,  and  he  could 
not  appreciate  the  loudest  noises  when  the  sound  ear  was  closed.  The 
paralysis  increased  every  day. 

A  few  days  after  this  the  eyelid  drooped,  and  he  found  it  impossible  to 
open  or  completely  shut  the  eye.  It  became  congested  and  irritated,  and 
he  experienced  a  burning  sensation  with  photophobia.  His-  condition 
grew  gradually  worse,  till  he  was  compelled  to  leave  his  employment  and 
seek  medical  aid.  He  never  had  had  otorrhcea  or  ear  affections  of  any 
kind,  nor  had  been  paralyzed.  His  habits  wei-e  good,  and  his  hereditary 
history  favorable.  When  he  applied  to  me,  I  found  paralysis  of  the  entire 
seventh  nerve,  motor  ocularis,  and  disturbance  of  the  sympathetic  of  the 
eye.  There  was  no  appreciable  power  in  the  orbicularis  oris,  levator 
labii  snperioris  et  alaeque  nasi,  or  other  muscles.  He  could  hardly  insert 
the  finger  in  the  mouth  without  pulling  down  the  jaw  with  the  other 
hand.  He  experienced  mastication  and  deglutition  from  involvement  of 
the  left  side  of  the  tongue,  which,  when  protruded,  inclined  to  the  right 
side.  With  this  there  was  indistinct  articulation,  and  I  was  led  to  infer 
paralysis  of  the  lingualis  muscle.  From  the  patient's  previous  history  I 
was  led  to  suppose  that  syphilis  was  the  primary  cause  of  the  trouble,  and, 
from  the  depth  of  the  lesion,  that  the  seventh  nerve  was  paralyzed  at  a 
point  above  its  division  From  the  specific  features  of  his  case  I  deemed 
the  iodide  of  potassium  to  be  the  best  remedy,  and  he  was  therefore  put 
upon  grs.  V  thrice  daily.  Hypodermic  injections  of  strychnia  and  atropia 
did  much  good  in  relieving  the  severe  cephalalgia.  Localized  galvan- 
ization was  resorted  to,  and  both  the  primary  and  secondary  currents 
used.  After  the  nerve  and  its  branches  had  been  pencilled  over 
with  stick  caustic,  one  electrode  was  applied  to  the  ramifications 
of  the  nerve,  while  the  other  was  placed  over  the  mastoid  process.  So 
succssful  was  this  treatment  that  after  a  daily  seance  lasting  twenty 
minutes,  in  three  weeks  the  patient's  face  was  much  more  symmetrical, 
and  the  act  of  mastication  improved.  The  pains  like  wise  disappeared 
under  the  same  current.  Occasional  directit  ns  of  this  and  the  fara- 
dic  current  over  the  eyelid  did  much  toward  the  improvement  of 
sight. 

It  now  occurred  to  me  that  Matteucci's  experiment  on  the  ear  might  be 
followed  by  gratifying  results;  so  its  cavity  was  filled  with  water,  and  one 
of  the  battery-wires,  finely  covered  with  sponge,  was  gently  introduced 
into  the  external  meatus.  After  four  weeks  his  hearing  was  so  markedly 
improved  that  he  easily  distinguished  loud  voices  when  the  sound  ear  was 
closed. 

November  12  (seven  weeks  after  commencement  of  treatment).  During 
the  application  of  the  current  the  face  resumed  its  expression,  and  he  was 
able  to  close  his  eye  completely.  He  is  greatly  improved;  injections  dis- 
continued. He  has  almost  complete  control  over  the  levator  palpebrie — 
this  is  marked  in  the  morning  ;  articulation  good. 


TRAUMATIC    PARALYSIS,  555 

28^/t.  Has  now  taken  the  battery  for  nearly  ten  weeks,  and  is  about 
to  discontinue  treatment.  The  face  is  perfectly  symmetrical,  and  the 
hearing  nearly  as  perfect  as  ever.  The  only  remaining  disfigurement  is  a 
slight  drooping  of  the  eyelid  on  the  affected  side  ;  appetite  good,  and, 
thoughemaciatedatfirst,  he  has  now  completely  regained  his  former  healthy 
condition. 

TRAUMATIC  PARALYSIS. 

Under  this  head  I  propose  to  speak  of  those  forms  of  lost  power  de- 
pendent upon  partial  or  complete  nerve-section,  or  pressure  made  upon  a 
nerve  in  its  course,  such  as  is  often  seen  in  a  familiar  form  known  as 
decubitus  paralysis,  as  well  as  in  the  loss  of  motility  produced  by  cold  or 
other  influences  which  may  affect  the  ramifications  at  the  peripheral  end 
of  a  nerve-trunk.  There  is  no  regularity  either  in  the  form  of  invasion, 
the  extent  of  the  paralysis,  or  its  locality.  Suffice  it  to  say,  that  both  upper 
and  lower  extremities  maybe  affected,  the  upper  especially,  and  that  such 
paralysis  is  not  bilateral.  The  liability  of  the  upper  extremities  to  this 
accident  is  probably  explained  by  their  use  in  many  of  the  necessary 
actions  of  everyday  life.  These  forms  of  paralysis  may  be  divided  into 
three  groups :  (1)  Paralysis  following  section  or  destruction  of  a  nerve- 
trunk  or  its  branches  ;  (2)  Paralysis  following  pressure ;  (3)  Paralysis 
following  cold,  or  general  disease. 

Division  of  a  Nerve-trunk. — If  the  section  be  complete,  the  paralysis 
will  be  equally  complete  and  immediate.  There  is  likely  to  be,  in  addi- 
tion to  lost  sensation  and  motion  in  the  muscle  supplied  by  the  nerve, 
various  trophic  defects,  which  may  consist  in  exfoliation  of  the  skin, 
and  in  changes  in  the  condition  of  the  nails,  which  become  curved,  cre- 
nated,  and  deformed  ;  and  sometimes  eruptions.  The  loss  of  motion,  of 
course,  will  depend  upon  the  importance  of  the  group  of  muscles  supplied 
by  the  nerve ;  and  it  does  not  follow,  by  any  means,  that  the  member  is 
utterly  useless,  as  some  muscles  may  escape  the  paralysis.  Should  sup- 
puration and  inflammation  occur  at  the  wound,  there  may  be  various  dis- 
turbances of  sensation,  and  aLo  lowered  temperature  in  the  paralyzed 
side. 

Goniudons  and  Pandured  Wounds. — The  injuries  produced  by  kicks, 
or  direct  violence,  when  the  skin  is  not  broken,  are  very  commonly  fol- 
lowed by  traumatic  paralysis.  These  are  likely  to  occur  when  the  nerve 
rests  upon  some  bony  prominence,  and  when  there  is  no  muscular  or  other 
cushion  to  make  the  blow  less  slight.  I  can  recall  cases  of  this  kind, 
one  in  particular,  where  the  individual  fell  in  the  street,  striking  his  elbow 
upon  a  projecting  stone.  There  were  no  immediate  symptoms  except  a 
tingling  and  sharp  pain,  but  in  a  fdw  days  there  was  loss  of  power,  and 
some  hypersesthesia  of  the  forearm. 

The  experience  of  surgeons  furnishes  us  with  numerous  examples  of 
peripheral  paralysis  from  dislocation.  Dr.  S.  G.  Webber,^  of  Boston,  has 
brought  forward  several  very  interesting  cases  of  this  variety,  with  dislo- 

1  Boston  Med.  and  Surg.  Journal,  Dec.  18,  1873. 


556  DISEASES    OF    THE    PERIPHERAL    NERVES. 

cation  of  the  humerus  ;  and  Oniraus  and  Legros^  a  case  which  "Webber 
presents  in  his  article  to  illustrate  a  form  of  paralysis  following  disloca- 
tion of  the  femur  : — 

"  A  man,  forty-six  years  of  age,  suffered  an  ilio-ischiatic  dislocation  of 
the  femur,  which  was  produced  by  violence  exerted  by  falling  rocks  and 
earth.  Severe  pain,  anaesthesia,  and  iratnobility  of  the  leg  existed  at 
first,  but  the  pain  subsequently  disappeared, and  the  anaesthesia  remained. 
After  an  attack  of  facial  erysipelas  the  pain  in  the  legs  returned.  Five 
months  later  the  left  leg  was  found  to  be  cold  and  smaller  than  the  other, 
and  oedematous  about  the  tibio-tarsal  joint.  The  leg  could  be  flexed  and 
raised,  but  the  foot  could  not  be  raised  nor  the  toes  extended.  Sensation 
was  diminished,  as  was  electro-muscular  contractility,  especially  in  the 
flexors  and  extensors  of  the  leg,  the  muscles  of  the  calf  and  the  peronei, 
as  well  as  the  tibialis  anticus  and  extensor  communis." 

In  "Webber's  case  of  paralysis  following  dislocation  of  the  humerus,  the 
biceps  and  deltoid  were  most  affected,  and  there  was  anaesthesia  over  the 
deltoid. 

J.  S.  came  to  the  N.  Y.  State  Hospital  for  Disease  of  the  Nervous  Sys- 
tem, June  9,  1871,  with  the  following  history  :  During  an  altercation 
with  a  fellow-laborer  he  was  thrown  off'  a  scaffold,  and  dragged  by  his 
right  arm  for  some  distance.  When  he  arose  he  found  that  the  whole 
arm  was  very  painful,  and  a  few  mornings  afterwards  the  right  wrist  be- 
came very  weak,  and  he  was  unable  to  grasp  any  object  or  move  his  fin- 
gers.    Sensation  was  unimpaired. 

Nerve-injury  following  dislocation  is  not  always  the  same,  there  being 
in  some  cases  simply  pressure,  and  in  others  rupture  of  the  nerves  by 
strain  ;  and  of  course  the  prognosis  depends  much  upon  the  fact  whether 
there  be  simple  contusion  or  actual  laceration,  as  there  was  in  a  case  re- 
ported by  Hilton. 

Pressure  upon  nerves  may  be  made  by  the  products  of  inflammation, 
cicatrices,  callous  tumors,  or  by  improperly  arranged  splints,  or  the  pres- 
sure of  a  crutch  or  some  hard  substance,  or  by  the  maintenance  of  a  con- 
strained position  for  an  extended  period.  The  products  of  a  periostitis 
may  exert  pressure  upon  a  nerve-trunk,  or  an  exudation  which  makes  com- 
pression either  in  its  course  or  at  its  ramification,  may  either  account  for  a 
paralysis.  There  is  always  some  painful  indication  at  first,  and  occasionally 
a  neuritis,  after  which  the  loss  of  power  takes  place.  Movement  of  the  limb 
aggravates  this  pain,  or  pressure  over  the  nerve  has  the  same  effect. 
Pressure  from  a  cicatrix  is  quite  rare,  and  it  is  only  when  very  extensive 
contraction  of  the  cicatrix  occurs  that  any  such  condition  of  aflfkirs  can 
exist.  So,  too,  is  pressure  from  callus  an  uncommon  cause  of  paralysis, 
and  but  a  few  cases  of  this  kind  have  been  mentioned. 

The  pressure  of  the  nerve  by  a  tumor  may  be  first  indicated  by  hyper- 
sesthesia,  and  secondarily  by  loss  of  motion  and  sensation,  and  the  dura- 
tion of  the  first  stage  depends  upon  the  site  of  the  tumor,  its  rapidity  of 


^  Traite  de  I'Electricite  Medicale,  Paris,  1872. 


TRAUMATIC    PARALYSIS.  557 

growth,  and  the  room  for  increase  in  size.  In  certain  situations  where 
there  are  bony  eminences  or  cavities,  and  where  there  is  no  room  for  ex- 
pansion of  the  mass  without  consequent  nerve-compression,  the  loss  of 
function  is  very  quickly  produced. 

By  far  the  most  familiar  form  of  peripheral  paralysis  is  that  which  fol- 
lows the  compression  of  nerves  during  the  continued  maintenance  of  a 
constrained  position,  the  nerve-trunk  being  pressed  against  some  bony 
eminence,  or  impinged  upon  by  some  tendon  or  muscular  mass.  The 
musculo-spiral  nerve  is,  from  its  exposed  position,  most  commonly  af- 
fected. The  common  modes  of  onset  may  be  the  following ;  The  patient 
falls  asleep  with  his  elbow  resting  upon  some  hard  substance,  and 
aw^akens  to  find  his  forearm  devoid  ot  power,  so  far  as  extension  is  con- 
cerned. There  is  some  anaesthesia  as  well.  The  following  are  ex- 
amples : — 

M.  P.  went  upon  a  spree,  and  when  he  became  sober  found  his  arm 
numb  and  cold,  and  devoid  of  power ;  muscles  respond  to  faradic  current; 
unable  to  force  dynamometer  column  to  6. 

T.  W.,  four  years  ago,  fell  asleep  with  his  left  arm  under  his  head  ; 
when  he  awoke  his  arm  was  numb  and  powerless.  Soon  after  formica- 
tion appeared.  After  seven  mouths,  pain,  which  subsequently  became 
paroxysmal,  began  in  the  arm,  coming  on  every  two  or  three  minutes. 
Kesponse  only  to  galvanic  current. 

In  one  case,  reported  by  Webber,  the  paralysis  was  the  result  of  carry- 
ing a  basket  of  lemons,  pressure  being  made  on  this  nerve. 

Mitchell^  speaks  of  paralysis  of  this  kind  resulting  from  the  most 
simple  causes.  In  one  case,  that  of  a  child,  pressure  was  made  by  a  string 
passing  over  the  finger.  And  in  other  cases  reported  by  Brinton,^  it  was 
found  that  the  paralysis  followed  the  rough  use  of  a  pair  of  cord  handcuffs 
upon  a  prisoner  who  was  being  taken  to  the  police  station. 

The  use  of  the  forceps  is  occasionally  attended  by  paralysis  of  the 
facial  nerves,  the  blades  of  the  forceps  making  pressure  upon  the  portia 
dura.  In  these  cases  there  is  paralysis  of  the  facial  muscles,  an  inability 
to  nurse  owing  to  the  paralysis  of  the  orbiculaiis  oris,  but  no  palatine 
loss  of  power,  which  serves  to  diagnose  the  effects  from  the  form  due  to 
intracranial  trouble.  The  mother  may  be  paralyzed  from  pressure  by 
the  forceps  exerted  upon  the  pelvic  nerves,  but  this  accident  is  an  ex- 
tremely rare  one. 

Accumulation  of  feces  produces  paralysis  generally  by  reflex  irritation, 
and  rarely  by  direct  pressure.  But  few  of  such  cases  have  been  reported, 
and  of  these,  one  detailed  by  PortaP  is  of  great  interest,  from  the  fact 
that  spinal  curvature  favored  the  accumulation  of  feces  and  the  exertion 
of  pressure  upon  the  nerves  of  the  lumbar  plexus. 


1  Op.  cit.,  p.  126. 

2  U.  S.  San.  Com.  Reports. 

^  Cours  d'Anatomie  Medicale,  t.  iv.  p.  276,  quoted  by  Mitchell. 


558  DISEASES    OF    THE    PERIPHERAL    NERVES. 

Cold  or  malaria  may  also  be  causes  of  a  form  of  peripheral  paralysis. 
In  speaking  of  facial  palsy  I  have  alluded  to  the  variety  known  as  the 
"Coup  de  vent."  This  sudden  origin  from  exposure  to  damp  and  wind 
is,  however,  much  more  rare  than  that  which  follows  intense  cold.  I  have 
had  several  cases  of  this  latter  kind  among  draymen,  sailors,  and  others 
who  have  been  obliged  to  work  for  a  protracted  period  in  an  exposed  place. 
There  is  at  first  a  numbness,  and  afterwards  a  complete  loss  of  power, 
which  may  be  bilateral. 

In  peripheral  paralysis  there  is  a  diminution  of  electro-muscular  con- 
tractility after  the  first  few  days,  and  if  there  be  complete  section  of  the 
nerve  this  susceptibility  to  electric  stimulation  is  lost,  first  to  the  faradic, 
and  at  the  end  of  a  week  or  two  to  galvanic  stimulation.  If  a  few  fi- 
bres remain  intact,  it  will  be  found  that  certain  muscles  are  unaflTected, 
and  of  course  electrical  irritation  meets  with  a  ready  response.  Changes 
of  color  in  the  paralyzed  limbs  are  the  rule,  and  there  may  be  an  ex- 
tensive blanching  or  patches  of  discoloration  dependent  upon  the  irregu- 
lar circulation.  Analgesia  and  anaesthesia  generally  exist  in  some  degree, 
while  changes  of  temperature  are  not  so  readily  perceived  as  on  the  sound 
side. 

As  the  nerve  is  restored,  electro-muscular  contractility  returns,  and  finally 
the  patient  is  enabled  to  produce  contraction  at  will. 

Arlong  and  Tripier'  have  alluded  to  the  rapid  return  of  sensibility  in 
distnl  parts  after  nerve  section,  and  explain  it  by  the  theory  that  there  are 
small  communicating  fibres  between  the  severed  portions,  but  this  view 
has  not  been  generally  received.  The  expression  of  certain  well-defined 
peripheral  paralyses  is  anatomically  the  following : — 

UPPER   EXTREMITY. 

Parnhjm  of  the  Circumflex  Nerve:  Loss  of  function  of  deltoid  and  teres 
minor  inurscles.  The  patient  i.s  cons^eqiiently  unable  to  put  his  hand  to  his 
head  ur  raise  it  from  his  shoulder.  The  skin  over  the  shoulder  is  anaes- 
thetic. 

Paralysis  of  the  Mmculo-Sjiiral  Nerve:  Loss  of  function  of  supinators 
and  cxti'iisors.  The  loss  of  power  is  quite  decided  and  there  is  some  ac- 
companying anesthesia  confined  to  the  back  of  the  forearm  and  a  jiart  of 
the  haid.  The  extensor  paralysis  of  the  middle  and  index  fingers  is  quite 
conspicuous. 

Piralijais  of  the  Ulnar  Ntrve :  L  )S3  of  function  of  many  of  the  import- 
ant (h'xors,  notably  of  the  f.  profundis  and  f.  carpi  ulnaris — sliown  in 
difficulty  of  flexing  hand  and  little  finger.  Adduction  is  enfeebled. 
Sensation  is  blunted  pretty  much  all  over  palmar  surface;  to  a  marked 
degree  over  thumb  and  over  the  two  inner  fingers  and  half  of  the  third 
finger. 

Paralysis  0/ the  Median  Nerve:  The  patient  presents  chiefly  evidence 

'  Juurnal  de  lAnntoinie  et  Pliyw  ,  eic  ,  M  iroh  and  April,  1876. 


TRAUMATIC    PARALYSIS.  559 

of  flexor  paralysis,  more  profound  than  in  last  mentioned  variety.  The 
muscles  of  the  ball  of  thumb  are  affected  so  that  it  is  extended  through 
antagonistic  contraction  of  extensors.  The  palm  of  the  hand  and  radial 
side  of  ring  finger  are  anaesthetic.  Through  paralysis  of  the  pronator 
radii  teres  he  cannot  pronate  his  hand. 

LOWER   EXTREMITIES. 

Paralysis  of  the  larger  nerves  does  not  commonly  occur  as  a  result  of 
pressure  or  injury  at  a  point  in  their  course  outside  of  the  pelvis. 
Sciatica  is  occasionally  attended  by  loss  of  motor  power,  and  aggravated 
glandular  disease  may  give  rise  to  crural  paralysis.  Syphilitic  infiltra- 
tion may  prove  to  be  the  origin  of  such  trouble,  or  aneurismal  swellings 
may  be  attended  by  the  evidence  of  neural  pressure.  Pain  and  surface 
anaesthesia  are  associated  with  such  paralyses.  Falls  and  blows  upon 
the  buttocks  may  give  rise,  in  rare  instances,  to  paralysis  of  the  muscles 
of  the  thighs  and  buttocks,  and  Wilks  speaks  of  the  wasting  of  the  glutei 
muscles  as  an  evidence  of  loss  of  power  and  an  accompaniment  of  certain 
neuralgic  affections. 

Paralysis  of  the  nerves  of  the  leg  interest  us  much  more,  and  as  a  con- 
sequence, we  are  furnished  with  weakness  in  the  movements  of  the  leg 
and  foot.  Peripheral  paralysis  resembling,  in  some  respects,  so  far  as  the 
loss  of  power  is  concerned,  certain  spinal  paralyses  of  organic  origin. 

Pir:dijm  of  the  Peroneal  Nerve :  Extensor  paralysis  of  muscles  sup- 
plied by  its  branches,  viz.  :  External  saphenous,  musculo-cut^neous  and 
anterior  tibial.  As  a  result,  the  muscles  upon  the  anterior  and  outer  part 
of  the  leg  and  toes  are  paralyzed  with  anaesthesia,  chiefly  of  the  integu- 
ment covering  the  anterior  part  of  the  leg,  and  the  inner  side  of  the  great 
and  second,  and  the  whole  of  the  third  and  fourth  toes,  and  the  inner  side 
of  the  little  toe. 

Paralysis  of  the  Posterior  Tibial  Nerve:  Loss  of  function  of  the  pos- 
terior muscles  of  calf,  and  the  flexors  and  abductors  of  toes.  There  is 
cutaneous  anaesthesia  of  the  plantar  surface.  The  anaesthesia  maybe 
confined  to  the  outer  side  of  the  fourth  and  little  toes. 

Diagnosis  and  Prognosis. — Progressive  muscular  atrophy  and 
cerebral  diseases  are  to  be  disposed  of,  and  if  we  see  the  case  alter  the 
onset  we  may  be  deceived.  In  the  former  it  must  be  remembered  that 
there  are  fibrillary  contractions,  and  that  the  atrophy  precedes  the 
paralysis.  The  electro-muscular  contractility  is  also  preserved  fur  some 
time. 

In  cerebral  paralysis  the  electro-muscular  contractility  is  preserved,  and 
if  anything  exaggerated.  Cerebral  palsies  do  not  involve  such  exteuj^ive 
sensory  impairment.  Spinal  paralyses  are  usually  bilateral,  a  fact  which 
distinguishes  them  from  peripheral  troubles. 

Mitchell  also  alludes  to  the  fact  pointed  out  on  a  previous  page,  that  in 
peripheral  palsies  there  is  none  of  the  delay  in  transmission  of  impression 
which  characterizes  either  spinal  or  cerebral  trouble. 


560  DISEASES    OF    THE    PERIPHERAL    NERVES. 

WestphaP  has  in  reviewing  an  admirable  article  by  Vulpian,^  referred 
to  the  various  interesting  pathological  changes  Avhich  follow  division 
of  spinal  nerves.  His  experiments  were  made  to  determine  the  muscle- 
changes  which  follow  separation  from  the  cord.  His  conclusions  may 
be  thus  summed  up  : — 

If  a  spinal  nerve  be  cut  through  at  any  point  between  the  spinal  gang- 
lion and  the  periphery,  the  nerve-fibres  of  the  central  portion  undergo 
atrophy  en  masse,  without  their  individual  character  being  altered  ;  but 
the  peripheral  part  of  the  nerve-trunk  undergoes  what  Vulpian  calls 
"  histopathic  change,"  i.  e.,  a  breaking  up  or  "  splitting"  of  the  medullary 
substance. 

Atrophy  of  muscles  follows  section  of  a  motor  nerve ;  and,  in  addition 
to  this,  electric  contractility  is  impaired. 

The  absence  of  central  symptoms  of  any  kind,  the  loss  of  both  motion 
and  sensation  in  a  limited  area,  absence  of  reflex  contractions  when  the 
sensory  fibres  are  irritated,  and  voluntary  motion  lost,  are  evidences  of 
the  peripheral  nature  of  these  paralyses. 

Treatment. — Traumatic  paralysis,  like  the  facial  form,  should  be 
treated  with  an  idea  of  removing  the  cause  should  it  exist,  and  afterwards 
restoring  the  integrity  of  the  nerve  and  muscles,  and  preventing  muscu- 
lar atrophy.  If  the  nerve-trunk  be  severed,  of  course  all  we  can  do  is  to 
await  the  union  of  the  divided  ends.  If  a  tumor  makes  the  destructive 
pressure,  it  should  be  removed  if  possible.  It  is  hardly  necessary  to 
allude  to  the  paralysis  following  dislocations,  for  of  course  the  surgical 
proceeding,  which  is  indicated  at  first,  is  the  reduction  of  the  luxated 
bones,  and  this  should  be  done  as  early  as  possible. 

In  the  management  of  paralysis,  which,  Desplats*  says,  may  be  due  to 
pressure  made  by  osseous  enlargements,  iodide  of  iron  and  other  proper 
remedies,  with  cod-liver  oil,  are  to  be  employed.  If  there  be  neuritis,  it 
should  be  met  with  counter-iri'itation,  emollient  applications,  or  leeches. 

General  supporting  treatment  may  be  necessary  if  there  be  a  depraved 
condition  of  the  system. 

The  three  valuable  local  forms  of  treatment  are:  1.  Electricity  ;  2. 
Strychnia,  internally  or  hypodermically  ;  3.  Massage. 

The  first  agent  may  be  used  as  early  as  possible.  If  one  current  will 
not  produce  contractions,  we  may  use  the  other ;  and,  if  complete  sever- 
ance of  the  nerve  has  taken  place,  it  may  be  necessary  to  employ  gal- 
vanism. Faradism  is  especially  valuable  should  there  be  anassthesia,  and 
may  be  applied  to  the  cutaneous  surface.  The  galvanic  current  may  also 
be  used  at'  the  same  time,  so  that  one  electrode  shall  be  applied  to  the 
spine,  and  the  other  to  the  extremity.  The  individual  muscles  are  to  be 
■subjected  to  daily  galvanic  stimulation. 

The  production  of  pain  is  unnecessary,  and  I  may  repeat  the  clinical 
rule  so  tersely  applied  by  H.   C.  Wood:*   "Always  select  the  current 

»  Centralblatt  fur  Med.  Wiss.,  July  13,  1872.  ^  Comptes  Eendu,  1872,  No.  15. 

*  Des  Paralyses  Periph^riques,  Paris,  1876,  p.  45.    *  Phila.  Med.  Times,  Feb.  20,  1875- 


TRAUMATIC    PARALYSIS.  561 

which  produces  the  most  muscular  contractions,  with  the  least  amount  of 
pain."  Pain  and  over-fatigue,  which  follow  the  use  of  a  strong  current, 
are  very  apt  to  thwart  any  probable  success.  The  application  should  last 
not  more  than  ten  or  fifteen  minutes  every  day. 

An  excellent  method  of  treatment  is  to  place  the  paralyzed  limb  in  a 
vessel  of  warm  salt  water,  and  to  introduce  therein  two  metallic  plates 
connected  with  a  faradic  machine.  If  there  be  neuritis,  induced  electricity 
does  great  harm  and  should  not  be  used. 

I  have  repeatedly  witnessed  the  beneficial  results  which  followed  the 
use  of  hypodermic  injections  of  strychnia.  An  injection  of  sV  of  a  grain 
may  be  thrown  under  the  skin  over  the  paralyzed  muscles.  This  may  be 
repeated  daily  ;  and  I  have  sometimes  seen  its  good  effects  when  electricity 
was  without  avail. 

The  use  of "  massage  "  should  be  employed  in  conjunction  with  the 
other  treatment,  and  the  muscles  should  be  separately  kneaded  and 
rubbed  for  an  half  hour  each  day.  This  auxiliary  treatment  is  of  immense 
value  when  there  is  suspected  rheumatic  exudation. 

I  have  often  employed  apparatus  by  which  the  paralyzed  limb  could 
be  subjected  to  warmth,  and  for  this  purpose  have  used  a  heated  drain- 
pipe lined  with  cotton-wool,  such  as  has  been  spoken  of  on  another  page. 
Into  this  the  patient  was  directed  to  place  his  arm  and  allow  it  to  remain 
for  an  hour  or  so  each  day  The  paralyzed  limb  may  be  wrapped  in  cot- 
ton and  oil  silk,  or  India-rubber  tissue. 

The  union  of  divided  ends  has  been  resorted  to  by  Tillaux,^  Xelaton, 
and  others,  and  with  a  great  deal  of  success.  In  Tillaux's  case  the  median 
nerve  was  united  by  sutures,  and  within  a  day  or  two  the  patient  was  able 
to  move  his  thumb,  and  there  was  some  return  of  sensation. 

MitchelP  employs  the  following  method:  He  carries  a  needle,  threaded 
with  one  or  two  threads,  through  the  loose  tissue  which  is  related  to  the 
nerve-sheath.  The  loops  are  drawn  with  care,  so  that  the  ends  are 
approximated.  Hot  and  cold  douches  and  electricity  are  subsequently 
used. 

In  some  cases  we  may  use  Van  Bibber's  apparatus. 

Van  Bibber  presented  the  following  care  to  the  Maryland  Medico- 
Chirurgical  Society  which  illustrated  the  beneficial  results  of  treatment  of 
this  kind : — 

"  A  youth,  eet.  16,  about  three  years  ago  sustained  a  fracture  of  the 
right  radius,  which  resulted  in  paralysis  and  atrophy  of  the  extensor 
group  of  muscles.  He  first  came  under  my  observation  about  three 
months  ago,  when  I  found,  the  following  condition  of  the  arm  :  radius 
curved;  hand  flexed,  and  the  flexors  acting  inordinately;  complete  atro- 
phy of  the  extensor  muscles,  it  being  impossible  for  him  to  move  his  hand; 
no  response  of  the  muscles  to  electricity;  and  the  skm  tightly  bound  over 
the  radiui.     The  treatment  has  consisted  in  rubbing  and  pinching  the  af- 


1  Quoted  by  Weir  Mitchell,  Dis.  and  Inj.  of  Nerves,  p.  238. 

■'  Ibid.,  p.  24.3. 

36 


562  DISEASES    OF    THE    PERIPHERAL    NERVES. 

fected  muscles,  the  application  of  electricity,  and  the  use  of  the  artificial 
muscle,  which  is  nothing  more  than  an  elastic  tubing  fixed  to  the  back  of 
the  arm.  The  results  of  treatment  have  been  very  satisfactory  ;  the  lost 
muscles  have  been  restored,  the  skin  has  regained  its  former  tone  and 
elasticity,  and  the  motion  is  fast  returning." 

I  may  in  conclusion  present  a  case  which  was  reported  by  Bernhardt, 
in  which  electricity  was  used. 

"  L.,'  43  years  old  ;  dislocated  his  left  humerus  by  falling  on  his  left 
shoulder.  He  had  pain  in  the  shoulder,  and  found  it  impossible  to  use 
his  arm,  and  that  felt  cold.  The  dislocation  was  found  to  be  subcora- 
coidal,  and  after  eight  days  it  was  reduced.  The  pain  ceased,  but  the  pa- 
ralysis continued.  In  the  palm  of  the  hand  there  was,  after  three  weeks, 
considerable  scaling  of  the  epidermis.  Pressure  on  the  shoulder  was  not 
painful,  but  a  strong  grasp  of  the  triceps  and  of  the  muscles  of  the  fore- 
arm was  unpleasant.  Occasionally  there  was  a  sense  of  formication  from 
the  middle  of  the  arm  down  the  extensor  side  of  the  forearm  to  the  end 
of  the  fingers  The  left  arm  could  be  raised  in  a  straight  line  forward 
about  half  a  foot,  but  could  not  be  carried  backward  nor  across  the  breast. 
The  forearm  could  not  be  bent  on  the  arm  ;  only  the  supinator  longus 
was  rendered  tense.  Extension  was  impossible;  supination  was  slight. 
The  hand  could  be  raised  somewhat.  Abduction  and  adduction  of  the 
hand,  flexion  and  extension  of  the  fingers,  were  impossible.  The  p-^ick 
of  a  needle  was  felt  to  the  upper  border  of  the  lower  third  of  the  arm  on 
both  sides  equally.  In  the  lower  third  of  the  left  arm,  in  the  elbow- 
joint,  and  the  upper  part  of  the  forearm,  the  skin  is  more  heusitive  on  the 
right  than  the  left.  In  the  rest  of  the  forearm,  in  the  hand  and  fingers, 
the  sensation  is  a  little  less  on  the  left  than  right,  but  nearly  equal.  The 
muscles  of  the  arm  and  forearm,  of  the  hand  and  finger,  as  well  as  the 
deltoid,  showed  only  the  slightest  reaction  to  the  induction  current. 
Likewise  the  use  of  a  very  strong  galvanic  current  either  to  nerve  or 
muscle,  by  opening  or  clo-ing,  failed  to  produce  contraction. 

"  From  the  5th  of  January,  every  other  day,  the  patient  was  treated 
with  a  strong  galvanic  current,  the  anode  and  the  cathode  being  placed 
on  the  paralyzed  muscles.  After  four  weeks  he  could  raise  the  arm  forty 
degrees,  also  some  distance  backward,  so  as  to  touch  the  right  shoulder 
with  the  left  hand.  Also,  he  could  bend  the  forearm  on  the  farm,  and  had 
some  motion  in  the  hand  and  fingers.  After  eight  weeks  more,  motion 
was  nearly  restored. 

DIPHTHERITIC  PARALYSIS. 

Diphtheritic  paralysis  may  either  take  place  as  a  feature  of  the  diph- 
theritic attack,  or  it  may  appear  during  convalescence,  or  even  several 
weeks  after  recovery.  The  paralysis  is  generally  bilateral,  and  does  not 
last  any  great  length  of  time  if  the  throat  is  alone  afiected,  and  rarely  ex- 
ceeds ten  or  fifteen  days  in  duration.  Should  the  loss  of  power  begin  at 
the  same  time  as  the  acute  disease,  the  progress  of  the  case  is  much  more 
apt  to  be  favorable,  and  the  paralysis  disappears  in  a  shorter  space  of  time 
than  if  it  occurs  at  a  period  subsequent  to  the  disease. 

^  Berliner  Kliniscbe  Wochenschrift,  No.  5,  1871. 


DIPHTHERITIC    PARALYSIS.  563 

Ijanne  states  that  a  marked  and  sudden  increase  of  temperature  during 
the  diphtheritic  attack  or  convalescence  is  indicative  of  paralysis. 

The  paralysis  may  be  simply  motorial,  or  there  may  be  a  corresponding 
loss  of  sensation  which  is  variable  in  extent. 

The  muscles  of  the  throat  are  usually  involved,  so  that  regurgitation  of 
fluids  takes  place  through  the  nose,  or  there  may  be  certain  phenomena 
which  are  so  well  marked  in  bulbar  paralysis,  in  which  the  lesion  is  one 
of  a  destructive  character.  When  the  limbs  are  paralyzed,  there  may  be, 
according  to  Brenner,  movements  of  a  choreic  character  which  depend 
upon  the  irregularity  of  the  paralysis,  the  antagonism  of  certain  groups 
of  muscles  being  abolished.  The  organs  of  special  sense  are  not  unusually 
involved.  There  may  be  paralysis  of  the  muscles  of  accommodation,^ 
neuro -retinitis,  and  sometimes  ptosis.  Deafness  is  not  rare,  and  in  one 
of  my  own  cases  there  had  been  tinnitus  immediately  preceding  the 
deafness. 

The  following  case  is  of  a  very  interesting  nature,  from  the  fact  that 
it  is  reported  by  the  patient  himself,  who  is  a  medical  man.^ 

"In  October,  1875,  being  twenty  six  years  of  age  and  in  good  health 
after  two  months'  constant  exposure  to  diphtheria,  I  was  inoculated  from 
a  child  two  years  old,  who,  on  examination,  coughed  portions  of  the 
membrane  into  my  face.  Six  days  after  this  exposure  I  was  seized  with 
a  chill,  followed  the  next  day  (October  28th)  by  the  appearance  of  a  diph- 
theritic deposit  on  one  tonsil.  The  deposit  was  limited  to  the  tonsils  and 
back  part  of  the  pharynx,  and  in  nine  days  disappeared.  Exhaustion 
and  great  gastric  irritability  retarded  convalescence.  Four  weeks  passed 
before  I  was  able  to  sit  up.  Two  weeks  after  convalescence  was  declared, 
a  sharp,  lacerating  pain  in  the  left  axilla  was  noticed,  recurring  two  or 
three  times  at  short  intervals.  In  a  few  days,  after  seeing  visitors  or 
talking  a  little,  severe  and  coQstant  pain  in  the  elbow-joints  occurred, 
which  soon  extended  to  the  muscles  of  the  arm  and  chest.  Afner  resting, 
these  pains  diminished  or  disappeared,  and  in  a  week  entirely  ceased. 
On  attempting  to  rise,  my  limbs  seemed  surprisingly  weak,  but  at  the 
expiration  of  the  sixth  week  a  short  walk  was  possible.  After  a  brief 
period  of  improvement  ray  legs  began  to  grow  uncertain  and  weak,  and 
Dy  December  10th  I  could  take  but  a  few  steps.  At  this  time  a  partial 
loss  of  sensation  came  on,  beginning  in  the  feet  and  gradually  progressing 
to  the  trunk,  together  with  a  feeling  of  coldness  in  the  feet,  which,  how- 
ever, were  not  cold  to  the  touch.  This  numbaess  increased  faster  than 
the  loss  of  raation.  Soon  after  its  appearance  in  the  lower  extremities 
the  ends  of  the  fingers  lost  their  sense  of  touch,  the  loss  of  power  also 
extending  iu  a  week  to  the  elbows,  and  at  no  time  greatly  affecting  the 
arm,  Ldss  of  motion  in  the  fingers  and  forearm  accompanied  it,  and 
increased  for  some  week^.  The  mouth,  tongue,  and  portions  of  the  face 
lost  their  sensitiveness  at  the  same  time  and  to  the  same  degree.  In  a 
few  days  my  voice  grew  thick,  and  was  soon  like  that  caused  by  cleft 
palate.  The  sjft  palate  and  uvula  hung  loosely  in  the  mouth,  and  on 
attempting  to  swallow  fluids  they  were  regurgitated  through  the  nares. 

1  See  cases  reported  by  Hutchinson,  Lancet,  Jan.  7,  1871. 

*  Dr.  A.  F.  Rsed,  Boston  Midical  and  Sjrgical  Journal,  July  13,  1876. 


564  DISEASES    OF    THE    PERIPHERAL    NERVES. 

Dimness  of  vision  for  a  short  time  prevented  reading.  In  three  weeks 
my  voice,  then  at  times  unintelligible,  grew  suddenly  better,  and  in  four 
or  five  days  was  restored.  The  difficulty  in  swallowing  also  soon  disap- 
peared. The  loss  of  motion  and  sensation  in  both  arms  and  legs  in- 
creased. In  walking  I  seemed  to  be  on  velvet;  there  was  a  sensation  of 
coldness  in  my  feet,  and  at  fii'st  the  circulation  was  retarded.  The  general 
loss  of  power  was  progressive  until  February  1st.  It  was  then  impossi- 
ble for  me  to  stand  alone  even  when  lifted  up,  to  raise  myself  an  inch 
from  the  chair  by  my  arm,  to  bring  my  thumb  and  forefinger  together, 
or  to  exercise  my  strength  in  any  part.  The  toes  hung  lifeless,  and  no 
reflex  action  was  produced  on  tickling  the  sole  of  the  foot.  The  urine 
was  voided  with  difficulty,  and  the  power  of  erection  was  gone.  The 
interosseous  muscles  were  wholly  paralyzed,  though  still  reacting  to  the 
faradic  current.  The  fingers  were  drawn  up  when  the  hand  was  at  rest, 
but  only  by  great  effort  could  be  straightened  out  again.  The  muscles 
of  the  arms  were  much  weakened,  but  with  those  of  the  thigh  retained 
more  power  than  the  i-est.  They  were  also  the  last  to  lose  and  the  first  to 
gain  motion.  All  these  muscles  were  more  or  less  responsive  to  the  faradic 
current,  the  gastrocnemius  least  of  all.  During  the  weeks  previous  and 
at  this  date  my  appetite  was  excellent,  and  my  food  well  digested.  From 
this  time  an  improvement  as  general  as  the  invasion  was  noticed.  In  one 
week  I  could  lift  my  body  in  the  chair  an  inch  or  two,  and  when  standing 
felt  more  secure.  Iq  two  weeks  I  could  raise  myself  up  from  the  chair 
mainly  by  my  arms,  and  undressed  without  aid.  At  the  end  of  three 
weeks  I  could  walk  about  the  room  aided  by  a  cane,  and  wrote  legibly. 
The  difficulty  in  voiding  the  urine  and  loss  of  power  of  erection  had  by 
this  time  gone.  In  four  weeks  I  walked  out  for  a  short  distance,  and  in 
two  weeks  more  all  paralysis  had  disappeared,  leaving  some  neuralgic 
pains  in  the  knees  and  feet,  which  lasted  but  a  short  time.  On  April  Ist 
I  walked  several  miles  without  great  fatigue.  Atmospheric  changes  made 
no  change  in  my  strength.  Insomnia  was  the  greatest  annoyance  suffered 
while  confined  to  the  house.  Three  or  four  hours'  sleep  was  all  that 
could  be  obtained.  The  loss  of  sleep  did  not,  however,  leave  me  unre- 
freshed. 

"  Treatment :  From  January  12th  faradism  to  the  muscles  every  day 
until  February  15th,  afterwards  three  times  a  week  for  three  weeks. 
Tincture  of  nux  vomica  and  tincture  of  phosphoric  ether  were  given  for 
ten  days.  The  stomach  rejecting  these,  one-thirtieth  of  a  grain  of  strych- 
nine was  substituted,  which  was  increased  to  one-fifteenth  three  times 
daily  for  six  weeks.  A  pint  of  ale  daily  for  two  months.  Friction  and 
kneading  of  muscles  every  morning  for  one  hour." 

Causes. — Morbid  Anatomy  and  Pathology. — Dowse  ^  quotes 
Balthazar  Foster,  who  has  stated  that  "  he  has  never  known  paralysis  to 
follow  the  non-febrile  form  of  diphtheria."  Dowse  thinks  that  the  vio- 
lence of  diphtheria  has  little  to  do  with  the  development  of  the  paralysis, 
and  says  that  he  has  seen  cases  following  modified  attacks. 

My  own  experience  leads  me  to  disagree   with  him.     I  have  seen  six 


1  See  case  reported  by  Dr.  A.  W.  Foot,  Dublin  Quarterly  Journal,  Sept.  1872,  p. 
176,  of  "  Locomotor  Ataxia  subsequent  to  Diphtberiu."  This  was  evidently  the 
ataxic  form  of  lirenner. 


DIPHTHERITIC   PARALYSIS.  565 

cases  of  diphtheritic  paralysis,  and  these  were  among  the  most  violent 
cases. 

Labadie  Lagrave,  Andral,  and  others  have  called  attention  to  the  blood- 
changes  in  this  disease,  viz.,  diminished  fibrine  and  an  increased  number 
of  white  corpuscles.  Saune  has  found  that  the  red  corpuscles  are  de- 
stroyed, and  that  there  is  a  great  increase  in  the  amount  of  debris  with 
albuminous  urine.  The  paralysis  takes  place,  however,  in  a  later  stage, 
but  Dowse  has  shown  that  the  albumen  in  the  urine  reappears  with  the 
paralysis,  and  that  it  again  diminishes  in  quantity  as  recovery  takes  place  ; 
hence  we  may  infer  that  a  connection  exists  between  the  blood  condition 
and  the  paralysis.  I  am  inclined  to  think  that  the  paralysis  of  the  palate 
and  muscles  of  the  pharynx  are  the  results  of  pressure  made  by  the  diph- 
theritic membrane. 

Diagnosis. — Diphtheritic  paralysis  need  not  be  mistaken  for  any  other 
affection,  though  occasionally,  in  its  ataxic  form,  it  is  confounded  with 
posterior  spinal  sclerosis.  Its  transitory  nature  should  render  such  an. 
error  as  this  impossible.  For  the  same  reason  it  should  not  be  confused 
with  organic  paralysis. 

Prognosis. — I  have  never  heard  of  a  fatal  case,  that  is, a  death  which 
was  a  result  of  paralysis  occurring  during  convalescence  from  diphtheria. 
When  paralysis  takes  place  before  the  violence  of  the  disease  has  been 
spent,  death  may  take  place  from  the  acute  disease.  The  duration  of  the 
paralysis  is  from  eight  or  ten  days  to  many  months. 

Treatment. — Nutritious  food,  massage,  strychnia,  and  iron,  quinine, 
and  stimulants  with  faradization,  are  the  indications.  The  plan  pursued 
in  Dr.  Reed's  case  will   serve  as  a  model  for  others  to  go  by. 


566  DISEASES   OF   THE   PERIPHERAL    NERVES. 


CHAPTER  XIX. 

DISEASES  OF  THE  PERIPHERAL  NERVES  (Concluded). 
LEAD   POISONING. 

Synonyms.— Colica  pictonum  ;  Plumbism. 

The  toxic  effects  of  lead,  whether  taken  iuternally'or  absorbed  by  the 
skin,  are  extremely  varied  and  interesting.  Disorders  of  motility  and 
sensation  are  produced  which,  though  rarely  alarming,  are  most  distress- 
ing conditions. 

Symptoms. — Among  the  early  symptoms  of  lead  poisoning  may  be 
mentioned  the  abdominal  pain  which  has  received  the  name  of  colica 
pictonum,  and  which  Romberg  ^  considers  a  species  of  neuralgia  of  the 
mesenteric  plexuses.  Tanquerel "  has  graphically  sketched  the  appearance 
and  development  of  this  symptom.  At  first  there  is  constipation  which 
lasts  for  some  weeks,  and  sometimes  follows  a  slight  diarrhoja,  while  after 
a  short  time  a  sense  of  epigastric  oppression  is  experienced,  with  nausea 
and  eructations,  and  gnawing  twisting  pains  which  occupy  the  umbilical 
region.  These  pains  are  much  worse  at  night,  and  rarely  shift  their  posi- 
tion.    Pressure  relieves  them  to  some  extent,  as  it  does  in  simple  colic. 

During  the  paroxysms  there  is  great  muscular  rigidity,  and  the  ab- 
dominal muscles  seem  to  be  rigid.  The  skin  is  cool,  and  perhaps  bathed 
in  sweat,  and  the  pulse  is  full  and  bounding,  and  quite  hard.  The  con- 
stipation continues,  and  the  feces  that  are  occasionally  voided  are  scyba- 
lous and  of  a  whitish-gray  color.  The  urine  is  of  high  specific  gravity,  is 
quite  light  in  color,  and  voided  in  considerable  amounts. 

The  complexion  of  the  individual  is  sallow,  and  the  skin  rough  ;  and, 
if  his  lips  be  separated,  the  peculiar  bluish  line'at  that  part  of  the  gums 
which  is  in  contact  with  the  teeth  will  be  seen.  This  line  is  a  quite  con- 
stant symptom ;  it  is  perhaps  one  of  the  most  valuable  diagnostic  marks. 
The  remaining  part  of  the  gums  is  quite  spongy  and  dark.     , 

There  may  be  in  conjunction  with  lead  colic  a  very  well-marked  cuta- 
neous anaesthesia  or  hyperte?thesia,  but  the  latter  is  more  common.  The 
skin  is  exqui-sitely  sensitive  in  parts,  such  as  the  scalp,  the  groin,  the  bend 
of  the  elbow,  and  other  like  regions.  Pressure  seems  to  relieve  this  ten- 
derness, but  light  irritation  aggravates  it  markedly. 

A  form  of  tremor  which  is  apt  to  be  confused  with  those  of  a  sclerotic 
nature  has  been  found  as  a  rare  symptom.     Brockman  observed  it  among 

^  Op.  cit.  vol.  ii.  p.  132. 

^  Traite  des  Maladies  de  Plomb.  ou  Saturninee,  1830. 


LEAD    POISONING.  567 

workers  in  the  lead  mines  of  the  Hartz  Mountains.  It  may  be  local  or 
general,  and  in  the  first  form  the  hands  are  affected.  The  lips  may  be 
agitated,  and  the  levator  anguli  oris  is  often  involved,  so  that  the  corner 
of  the  mouth  is  drawn  up.  In  the  other  form  the  head,  trunk,  and  arms  are 
all  in  a  state  of  tremor,  the  head  being  bowed  on  the  chest,  and  the  legs 
unsteady.     In  this  latter  form  there  is  usually  a  profound  toxic  condition. 

By  far  the  most  important  symptom,  and  one  which  may  or  may  not  be 
preceded  by  lead  colic,  is  the  form  of  local  paralysis  known  as  'lead 
palsy"  or  "  lead  paresis."  The  onset  of  the  malady  is  usually  gradual, 
the  patient  being  unable  at  first  to  extend  the  fingers.  There  is  nearly 
always  some  numbness  of  the  hand,  and  rarely  tremor.  It  is  not  often 
that  the  paralysis  becomes  general,  but  the  extensors  of  the  forearms  are, 
as  a  rule,  involved.  In  this  condition  the  hands  hang  helplessly,  and  an 
appearance  results  which  has  been  called  "drop  wrist."  There  is  gen- 
erally some  paralysis  of  the  flexors,  but  this  is  almost  inappreciable. 
Other  muscles,  notably  those  of  the  shoulder,  are  affected  if  the  lead 
saturation  be  profound,  and,  as  a  consequence,  the  patient  maybe  unable 
to  raise  his  arm.  I  have  never  seen  a  case  in  which  the  lower  extremities 
were  involved. 

Electric  sensibility  and  contractility  are  much  reduced,  and  there  is 
marked  anaesthesia  in  most  of  the  cases.  Faradism  rarely  provokes  mus- 
cular contractions,  and  in  old  cases  even  the  galvanic  current  fails  to  call 
forth  the  slightest  response. 

Atrophy  is  a  result  of  the  paralysis,  and  the  interosseous  spaces  of  the 
forearm  are  sometimes  very  plainly  marked,  the  loss  of  substance  being 
quite  decided. 

The  colic  generally  subsides  with  the  appearance  of  the  paralysis,  and 
according  to  Romberg  ^  the  two  conditions  rarely  co-exist.  In  the  cases 
recorded  by  various  observers  the  muscles  of  both  extremities  of  one  kind 
were  affected  in  the  great  majority  of  instances,  and  from  my  own  expe- 
rience I  consider  unilateral  lead  paralysis  to  be  an  anomalous  condition, 
but  impaired  function  not  equal. 

Occasionally  a  cerebral  condition  results  from  lead  poisoning,  and  gene- 
rally follows  the  colic.  This  is  characterized  by  vertigo  and  headache, 
general  malaise,  and  tremor  of  the  hands  which  is  aggravated  by  volun- 
tary action,  A  more  serious  state  is  sometimes  produced,  however,  which 
is  symptomatized  by  delirium,  convulsions,  and  stupor. 

The  duration  of  lead  paralysis,  or  the  other  conditions  I  have  noticed, 
is  of  course  governed  by  the  existence  of  the  cause  and  the  exposure  of  the 
patient.  Most  of  the  toxic  lead  states  disappear,  however,  in  a  very  short 
time,  provided  the  patient  protects  himself  by  leaving  his  injurious  occu- 
pation, and  the  proper  remedies  be  administered. 

The  following  may  be  cited  as  a  well-marked  case  of  lead  poisoning: — 

Jas.  McK.,  set,  55,  N,  Y.  City,  painter.  Has  followed  his  trade  35 
years,  engaged  mostly  on  "inside  work,"  "flatting."      Never  had  any 

1  Op.  cit.,  vol.  ii.  p.  136. 


568  DISEASES    OF    THE    PERIPHERAL    NERVES. 

trouble  till  two  years  ago,  when  he  noticed  pains  in  his  limbs,  back,  and 
suboccipital  region  ;  not  much  colic,  but  some  nausea;  loss  of  appetite  ; 
not  constipated.  While  actually  engaged  in  work  he  became  dizzy,  and 
"  a  blur  came  across  his  eyes."  Last  acute  attack  was  obliged  to  leave 
work  suddenly  on  account  of  severe  backache.  He  then  noticed  a  loss  of 
power  in  right  hand.^  He  consulted  me  in  July,  1877,  presenting  well- 
marked  "  wrist  drop,"  so  that  he  was  unable  to  extend  his  hand.  He  com- 
plained of  formication  of  soles  of  feet,  insomnia,  and  pains  in  shoulders, 
knee-joints,  and  about  heart.  Well-marked  blue  line  and  very  dirty  gums. 
The  necks  of  the  teeth  are  carious  and  black,  and  he  has  lost  several  of 
them  during  the  past  few  years. 

Loss  of  sensation  of  cutaneous  surface. 

Hand  — Atrophy  of  adductor  of  thumb,  so  that  quite  a  hollow  exists. 

Forearm. — Complete  loss  of  electro-muscular  contractility  in  common 
extensor  of  right  forearm ;  slight  power  under  electrical  stimulus  of  ex- 
tensor of  thumb  and  little  finger.  Flexors  slightly  impaired,  but  con- 
tractility scarcely  lost. 

Arm. — Muscles  all  contract  well.  Patient  cannot  take  off  his  coat  or 
underclothing,  or  cannot  button  his  clothes. 

Treatment — Electricity  and  potass,  iodid.  with  strychnine. 

Causes. — The  majority  of  cases  of  lead  poisoning  arise  from  the  inspi- 
ration of  finely  divided  particles  of  lead,  and  not  from  the  manipulation  of 
pieces  of  the  metal ;  consequently,  painters,  smelters,  white-lead  makers, 
and  miners  are  more  often  victims  than  auy  other  classes  of  individuals. 
There  seems  to  be  an  idea  that  printers  are  especially  subject  to  lead  dis- 
eases ;  and  at  the  request  of  the  Board  of  Health  of  the  city  of  New  York 
I  made  an  extensive  examination  of  the  printing  offices  for  the  purpose 
of  testing  the  question.  I  interviewed  nearly  1500  men,  women,  and 
children,  and  found  not  a  single  case  of  paralysis.  Among  the  grinders 
of  type  (those  who  smooth  the  sides  and  ends  of  the  type  against  large 
rough  stones),!  found  that  the  persistent  use  of  the  muscles  of  the  thumb 
and  forefinger,  in  one  case,  resulted  in  a  condition  resembling  progressive 
muscular  atrophy.  In  the  lead  pipe  and  shot  manufactories  my  expe- 
rience was  the  same. 

The  painters,  however,  seem  to  be  most  frequently  poisoned.  An  oj^e- 
ration  known  as  "  flatting,"  in  which  the  painter  closes  all  the  doors 
and  windows  of  a  room,  and  applies  thin  paint,  is  attended  with  great 
danger.  The  turpentine  evaporates  rapidly,  and  carries  with  it  minute 
particles  of  lead  which  the  workman  must  inhale. 

Dr.  Richardson,^  in  a  thesis  which  embodies  a  large  amount  of  valuable 
research,  thus  describes  the  manner  of  preparing  white  lead,  and  the  dan- 
ger which  attends  its  manufacture. 

"  The  metal  first  comes  in  contact  with  the  skin  of  the  men  in  being 
carried  by  hand  from  the  cars  to  the  melting-roora.  Here  many  tons  are 
melted  at  once  and  cast  into  thin,  circular,  perforated  plates  called  buck- 

1  Can  only  force  dynamometer  index  to  4  with  right  hand ;  left,  15, 
■^  Graduation  Thesis,  Harvard   Medical  School — Boston   Med.  and   Surg.  Journ., 
Oct.  4, 1877. 


LEAD    POISONIKG.  569 

]es,  of  sucli  shape  as  to  expose  as  much  surface  as  possible  for  the  weight. 
The  temperature  is  very  high.  Bathed  in  perspiration  the  men  stand  for 
hours  inhaling  the  minute  particles  of  the  oxide  of  lead  which  escape 
from  the  cooling  buckles  and  fill  the  air.  Their  thirst  in  this  part  of  the 
process  is  insatiable,  and  enormous  quantities  of  ice-water  are  swallowed, 
whereby  the  dust,  which  adheres  to  the  tongue  and  lips,  is  washed  directly 
into  the  stomach. 

Having  been'  carried  to  a  neighboring  shed,  the  buckles  are  placed 
over  pyroligneous  acid  in  earthen  pots  of  about  four  quarts  capacity. 
Many  thousands  of  these  pots  are  packed  together  in  the  refuse  of  sta- 
bles or  the  exhausted  bark  from  tanneries,  and  are  exposed  to  the  mode- 
rate heat  which  is  spontaneously  generated  about  them.  The  wood  vine- 
gar is  volatilized  and  rises  through  the  buckles,  changing  by  some  obscure 
chemical  reaction  the  blue  metallic  lead  into  the  white  carbonate.  After 
an  exposure  of  this  sort,  lasting  from  six  weeks  to  three  months,  the  pots 
are  unpacked  and  the  whitened  lead  removed.  Here  for  hours  men 
breathe  the  vapors  rising  from  the  heated  bark,  loaded  with  poisonous 
particles  of  the  now  dusty  metal.  In  English  mills  this  part  of  the  pro- 
cess is  done  by  women,  with  most  disastrous  effects  upon  the  health.  To 
separate  the  blue  from  the  white  lead  the  buckles  are  placed  in  a  revolv- 
ing cylinder  of  wire-cloth,  through  which  the  carbonate,  more  or  less  pul- 
verized, falls.  The  blue  portion  remains  in  the  cylinder  and  is  melted 
again.  To  be  in  this  room  without  protection  is  suicidal,  for  the  air  is 
filled  with  visible  clouds  of  dust  The  utmost  care  must  be  taken.  The 
mouth  and  nostrils  are  covered  by  a  moist  sponge  to  catch  the  floating 
particles.  The  skin  and  clothes  quickly  become  white  with  lead.  The 
semi-powdered  metal,  having  been  shovelled  into  barrels  and  rolled  into 
another  division  of  the  works,  is  mixed  with  water  and  finely  ground. 
When  it  fills  the  water  as  a  milky  precipitate,  the  whole  is  drawn  off  and 
dried  on  long  tables  at  a  temperature  of  140°  F.  Formerly  the  grinding 
was  done  without  water,  and  the  lead  sickness  was  much  more  common 
than  now.  The  di'ying-room  is  the  most  poisonous  one  in  modern  mills. 
It  combines  the  effects  of  the  dust  which  fills  the  air  with  those  of  a 
heated  atmosphere.  Here,  as  in  the  melting-room,  the  skin  is  kept  in 
the  best  state  for  absorption.  A  terrible  thirst  makes  the  men  swallow 
large  quantities  of  cold  water  with  the  lead  which  accumulates  on  their 
lips  and  tongues,  while  at  every  breath  fine  dust  is  drawn  into  the  lungs. 

The  general  appearance  of  the  men  is  not  good.  The  faces  are  sallow 
and  more  or  less  worn.  The  sclerotic  coat  is  yellowish.  Their  motions 
are  far  from  energetic,  and  in  some  cases  eccentric  and  unsteady.  One 
would  say  immediately,  I  think,  that  the  general  appearance  is  much  be- 
low that  of  the  average  workman. 

1.  The  first  man  examined  has  worked  in  all  parts  of  the  mill  for  thir- 
teen years.  His  only  trouble  is  rheumatism.  The  gums  show  a  distinct 
blue  line  along  the  border. 

2.  After  seven  years  in  the  corroding  rooms  has  no  symptoms  except- 
ing the  blue  line. 


570  DISEASES    OF    THE    PERIPHERAL    NERVES. 

3.  After  grinding  lead  with  oil  has  only  the  blue  line. 

4.  After  working  in  all  parts  of  the  mill  for  six  months  has  had  violent 
colic  and  great  constipation.     Blue  line  marked. 

5.  Reports  only  blue  line  after  four  years'  work. 

6.  The  machinist,  after  repairing  in  the  drying-room  a  few  hours  a  day 
for  ten  days,  was  affected  with  colic  and  constipation.  Has  great  habitual 
constipation.     Blue  line  very  marked. 

7.  After  seven  years  only  blue  line. 

8.  After  twelve  years  has  only  blue  line  and  fungous  bleeding  gums, 
with  occasional  colic  and  obstinate  constipation. 

9.  After  six  years  in  corroding-room  has  only  blue  line. 

10.  Has  worked  in  all  parts  of  the  mill  for  fifteen  years  without  showing 
a  trace  of  blue  line  or  any  other  symptoms  whatever.     Very  neat. 

11.  After  three  years  only  blue  line. 

12.  After  four  years,  nothing. 

13.  Blue  line,  rheumatic  pains,  and  fainting  fits.  This  was  a  remark- 
ably neat  man. 

14.  After  four  years  no  trace  of  poisoning. 

15.  After  four  years  entirely  used  up.     Had  to  leave  all  work. 

16.  After  one  year's  work  completely  crippled,  having  paralysis  of  the 
extensors,  aphonia,  and  general  debility. 

17.  The  carpenter,  after  repairing  ten  days  in  the  drying-room,  had  se- 
vere colic,  obstinate  constipation,  and  persistent  blue  line. 

18-75.  Of  the  rest  of  the  seventy-five  men  whom  I  examined  all  had  a 
distinct  blue  line  about  the  gums,  and,  with  one  or  two  exceptions,  habit- 
ual constipation.  There  was  nothing  further  than  this  to  suggest  the 
presence  of  lead. 

In  addition  to  the  above  cases,  three  of  the  former  employes  had  suf- 
fered with  difficulty  in  speaking,  three  with  amaurosis,  several  with  cere- 
bral troubles,  and  many  with  paralysis.  The  superintendent  has  ob- 
served that  the  most  frequent  complaint  has  been  of  swollen  joints  and 
aching  bones.  In  the  numerous  cases  of  paralysis  which  he  has  seen 
during  many  years'  service  at  these  works,  he  has  noticed  that  the  wrists 
have  become  much  swollen  before  paralysis  of  the  extensors.  A  curious 
tradition  exists  among  them  that  they  cannot  drink  alcoholic  liquors  and 
keep  up  with  their  work,  like  laboring  men  in  other  manufactories.  Sev- 
eral cases  were  told  me  of  men  who  quickly  succumbed  to  the  influence  of 
the  lead  after  beginning  the  use  of  strong  stimulants." 

Lead  is  often  taken  into  the  stomach  without  the  knowledge  of  the 
individual,  and  lead  pipes  are  a  prolific  source  of  the  contamination  of 
water.  I  have  seen  three  cases  in  the  same  family  caused  by  tea  which 
had  been  made  from  a  specimen  containing  particles  of  sheet  lead  which 
had  lined  the  box.  The  last  two  or  three  pounds  were  impregnated 
with  these  impurities,  which  had  settled  to  the  bottom  of  the  chest.  It 
was  the  custom  to  make  tea  and  from  time  to  time  to  add  fresh  leaves  and 
pour  on  hot  water,  so  that  there  was  constantly  a  quantity  of  lead  sub- 


LEAD   POISONING,  571 

jected  to  the  action  of  the  fluid.  Upon  analysis,  quite  an  amount  of  lead 
was  found. 

Cases  arising  from  the  use  of  cosmetics  and  hair-dyes  are  two  common 
to  need  anything  more  than  bare  mention. 

Morbid  Anatomy  and  Pathology. — Andral  and  Tanquerel^ 
were  unable  to  discover  any  pathognomonic  condition  of  the  intestines  in 
lead  colic;  but  the  latter  authority  found  lead  deposits  in  the  intestines, 
muscles,  and  nervous  substances.  In  a  case  of  lead  paralysis  reported  by 
Gombault,^  there  was  found  to  be  no  change  in  the  cord,  and  the  only 
morbid  appearances  anywhere  else  were  in  the  nerves,  the  medullary 
substance  having  undergone  a  granular  alteration.  No  other  appear- 
ances which  might  clear  up  the  pathology  of  the  affection  have  been 
seen. 

Kemak^  is  of  the  opinion  that  lead  palsy  is  a  central  disease,  and  he 
presents  several  cases  to  show  its  likeness  to  infantile  paralysis.  The 
same  electrical  reaction  of  the  muscles  in  these  two  affections,  and  the 
fact  that  groups  of  muscles  are  affected  which  act  together,  not  neces- 
sarily being  those  supplied  by  the  same  nerve,  leads  him  to  think  that  the 
paralysis  is  of  central  origin.  The  blue  line  of  the  gums,  which  indicates 
plumbic  saturation,  was  first  described  by  Burton  in  1840.  By 
Tanquerel  it  is  supposed  to  be  produced  by  the  decomposition  of  food 
about  the  teeth,  the  sulphuretted  hydrogen  uniting  with  the  lead.  It 
occurs  in  people  who  brush  their  teeth  as  well,  however,  as  in  those  of 
careless  and  untidy  habits.  Dr.  Richardson  *  tried  the  following  experi- 
ment : — 

"  A  strong,  healthy  cat  was  fed  for  a  week  upon  milk,  to  which  had 
been  added  a  small  portion  of  a  solution  of  plumbic  acetate.  At  the  end 
of  a  week  the  animal  was  killed,  after  having  shown  symptoms  of  severe 
constitutional  disturbance.  The  lower  jaw  was  excised,  and  the  gums 
found  perfectly  clean.  The  upper  jaw  was  also  clean.  The  lower  jaw 
was  placed  in  water,  through  which  a  stream  of  sulphuretted  hydrogen 
was  passed  for  several  hours.  At  the  end  of  that  time  a  perfectly  distinct 
and  unmistakable  blue  line  was  found  throughout  the  juncture  of  the  gum 
with  the  teeth.  The  stomach  and  intestines  of  the  animal  showed  nothing 
remarkable.  The  presence  of  the  blue  line  seems,  therefore,  to  depend 
on  a  certain  amount  of  putrefaction  about  the  teeth." 

The  elimination  of  lead  is  usually  rapid  when  the  proper  remedies  are 
administered  to  convert  it  into  a  form  for  excretion.  If  nature  is  left  to 
herself,  the  process  is  more  slow.  Potain  considers  that  it  is  eliminated 
only  very  slowly  by  the  swcat-glands,  and  not  by  the  kidneys  or  salivary- 
glands,  but  I  am  disposed  to  consider  that  elimination  does  take  place  by 
the  kidneys. 

1  Tanquerel,  p.  326. 

^  Archives  Generales,  1873. 

^  Arohiv  fiir  Psycliiatrie  and  iServenkrankheiten,  vi.  p.  1. 

*  Op.  cit. 


572  DISEASES   OF   THE   PERIPHERAL   XERVES. 

Diagnosis. — lu  nearly  all  cases  of  lead  poisouing,  it  is  usually  pos- 
sible to  detect  the  cachexia,  which  is  so  well  expressed  by  the  different 
signs  I  have  enumerated.  If  our  suspicions  are  not  verified  by  appear- 
ances in  an  acute  case,  we  may  test  the  patient's  urine.  A  few  drops  of 
a  solution  of  pota^sic  sulphide  will  usually  precipitate  any  lead  that  may 
be  present  in  the  form  of  a  black  sulphide. 

The  paralysis  may  be  sometimes  confounded  with  other  forms,  but 
when  it  is  remembered  that  the  extensors  are  prominently  affected,  and 
that  there  are  lead  symptoms  at  some  time  or  other,  it  is  not  possible  to 
be  misaken. 

Dr.  Wharton  Siukler,'  in  an  admirable  paper,  calls  attention  to  the 
resemblance  between  '*'  wrist  drop  "  due  to  lead  poisoning,  and  paralysis 
of  the  extensors  from  injury  of  the  musculo-spiral  nerve.  H3  has  found 
paralysis  of  the  flexors  of  the  forearm  after  injury  of  the  nerve,  and  he 
is  inclined  to  think  that  in  the  beginning  there  is  never  paralysis  of  the 
flexors  in  lead  palsy.     In  lead  paralysis  the  supinators  escape. 

Prognosis. — With  the  disappearance  of  the  cause,  we  may  expect  in 
most  cases  a  rapid  subsidence  of  symptoms.  It  is  true  the  pai'alysis  often 
lasts  for  some  time,  but  even  this  ultimately  disappears.  Deaths  by  lead 
poisoning  are  rare,  and  I  suppose  when  they  occur  are  due  to  an  affection 
of  the  brain,  to  which  I  have  alluded.  The  mortality  from  lead  poison- 
ing in  Xew  York  City  from  1852  to  1873  was  288.  48  died  in  185-  ;  and, 
strange  to  say,  but  four  in  1872.' 

Treatment. — If  we  have  correctly  diagnosed  the  condition,  our  ob- 
jects must  be :  1.  To  relieve  pain  ;  2.  To  favor  elimination  of  the  lead  ; 
3.  To  guard  our  patient  against  being  continually  affected  ;  4.  To  restore 
the  paralyzed  limbs. 

1.  Xo  better  remedy  is  possessed  than  iodide  of  potassium,  which  forms 
an  iodide  of  lead  which  is  an  innocuous  salt.  This  drug  must  be  given 
in  moderate  doses,^  and  its  elimination  hastened  by  mild  purgatives.  It 
will  be  found  that,  if  the  patient  is  obliged  to  continue  at  his  work,  small 
doses  taken  daily,  or  acidulated  drinks,  will,  in  some  measure,  prevent 
the  absorption  of  lead.  If  there  be  colic,  the  hypodermic  use  of  mor- 
phine will  give  great  relief. 

It  has  been  found  that  those  workmen  who  drink  a  great  deal  of  milk 
seem  to  escape  the  danger  of  lead-poisoning.  In  France  the  workmen  in 
the  lead-works  are  obliged  to  drink  milk,  and  it  is  fuund  to  be  an  excel- 
lent prophylactic.  Richardson's  case  (Joe.  cit.)  did  not  suffer  so  long  as 
he  kept  his  cows ;  but  when  he  parted  with  these  animals,  and  stopped 
drinking  milk,  the  most  decided  symptoms  of  plumbism  manifested  them- 
selves. 

As  to  the  employment  of  electricity,  it  is  well  to  use  the  faradic  cur- 
rent if  possible ;  but  in  some  cases  this  produces  no   contractions.     In 

1  Am.  Psjch.  Journal,  Nov.  1875,  p.  31. 

-  Report  of  the  Board  of  Health,  1S72. 

"  Verv  largetloses  seem  to  increase  the  symptoms. 


LEAD    POISONING.  573 

such  an  event  we  may  begin  with  the  slowly  intermitted  galvanic  current ; 
and,  after  a  while,  it  will  be  found,  as  in  some  other  paralyses,  that  the 
faradic  will  cause  muscular  response,  particularly  if  the  arm  be  so  sup- 
ported that  the  muscles  shall  be  relaxed.  Dr.  H.  C.  Wood,^  of  Phila- 
delphia, has  noticed  the  fact  that  voluntary  power  may  return  to  a  great 
degree  without  a  corresponding  return  of  electric  contractility. 

I  have  before  alluded  to  an  instrument  devised  by  Dr.  J.  Van  Bibber,^ 
and  it  is  well  to  apply  this  so  that  the  muscles  may  be  entirely  supported. 

In  conclusion,  I  may  present  the  records  of  a  representative  case  of 
lead  palsy.  The  patient  was  under  the  care  of  Dr.  Cross,  through  whose 
kindness  I  had  the  opportunity  of  seeing  him: — 

M.  C.,''  aged  32  years,  single,  born  in  Ireland,  a  painter  by  occupation. 
He  has  been  moderately  temperate  in  his  habits,  and  has  always  enjoyed 
good  health  until  1863.  when  he  was  suddenly  seized  with  a  severe  attack 
of  colic,  which  was  preceded  by  great  constipation  of  the  bowels  and  loss 
of  appetite.     There  soon  succeeded  nausea  and  vomiting  of  bile,  accom- 


1  Phila.  Med.  Times,  Feb.  20,  187-5. 

''  "  After  many  attempts  to  secure  this  advantage  by  means  of  strips  of  plaster,  it 
was  determined  to  try  the  India-rubber  muscle  as  used  by  Dr.  Lewis  A.  Sayre  in 
orthopedic  surgery.  Tlie  great  difficulty  in  the  use  of  such  an  appliance  was  to 
effect  its  application  without  causing  injurious  pressure  upon  the  circulation  of  the 
arm  and  hand.  I  am  not  aware  that  these  elastic  tubes  have  been  used  before  to  cor- 
rect this  deformity,  or  attached  by  a  method  so  simple  and  so  free  from  pressure  as 
that  wiiich  I  shall  now  describe.  Two  bands  of  inelastic  webbing,  pierced  by  eyelets 
at  certain  points,  and  each  having  a  convenient  buckle,  serve  as  points  of  attach- 
ment. The  one  for  the  hand,  about  three  quarters  of  an  inch  wide,  so  made,  that 
the  free  end  placed  upon  the  palm  pointing  toward  the  thenar  eminence,  and  the 
eyelet-hole  resting  on  the  ball  of  little  finger,  the  band  folded  once  around  tliat  finger 
and  passed  over  dorsum  of  the  hand,  the  buckle  would  come  in  a  convenient  place 
upon  the  palmar  surface.  The  band  for  the  arm  about  one  inch  in  width,  so  arranged 
that  the  eyelet  being  placed  upon  a  line  a  little  above  the  external  condyle,  the  buckle 
would  rest  upon  the  internal  surface  of  the  arm. 

As  seen  by  the  illustration,  two  transverse  strips  of  plaster  are  adjusted  to  the 
arm  so  as  to  form  an  angle  just  below  the  eyelet,  and  thus  relieve  the  band,  which 
should  be  buckled  loosely,  from  all  injurious  traction.  The  fold  around  the  little 
finger,  and  the  muscle  resting  upon  the  webbing  on  the  dorsum  of  the  hand,  enable 
us  to  buckle  the  band  loose  enough  to  insure  perfect  abduction  of  all  the  fingers. 
Finally,  a  piece  of  India-rubber  tubing  of  correct  length  and  medium  elasticity,  with 
one  of  Dr.  Sayre's  metallic  hooks  attached  at  each  end,  constitutes  the  entire  appa- 
ratus. 

Looking  upon  this  artificial  muscle  as  performing  to  some  extent  the  duty  of  those 
paralyzed,  I  can  probably  best  describe  its  application  by  saying,  in  anatomical 
language,  that  it  arises  from  a  point  a  little  above  the  external  condyle,  and  passing 
downward  on  the  extensor  surface  of  forearm,  under  the  cuff,  which  we  might  call 
the  annular  ligament,  forward  over  dorsal  aspect  of  the  hand,  passing  between  the 
index  and  second  fingers,  which  serve  as  a  trochlea  or  pulley,  then  transversely 
across  the  palmar  surface  of  the  hand,  and  is  inserted  at  a  point  about  the  articula- 
tion of  the  fifth  metacarpal  bone  with  its  first  phalange.'' — JV.  Y.  Medical  Jounial, 
May.  1874. 

'^  Reported  in  the  Psychological  Journal,  Jan.  1871,  by  Dr.  Cross. 


674  DISEASES    OF    THE    PERIPHERAL    NERVES. 

panied  by  an  acute  lancinating  pain  in  the  epigastric  region,  which  was 
so  severe  that  the  patient  was  obliged  to  lie  flat  on  the  floor  and  press  his 
abdomen  strongly  against  that  surface,  in  order  to  obtain  temporary  relief. 
These  symptoms  continued  off  and  on  for  a  period  of  about  two  weeks, 
gradually  diminishing  in  severity,  however,  especially  after  an  evacuation 
from  the  rectum,  which  was  only  obtained  with  the  greatest  difficulty. 
His  right  leg  at  this  time  became  oedematous.  In  the  course  of  two  months 
he  resumed  his  usual  avocation,  that  of  a  painter,  but  was  not  aware  at 
this  time  that  his  sickness  had  been  caused  by  the  action  of  lead.  During 
the  year  1867  his  bowels  again  became  very  costive;  and  his  stools,  which 
c  insisted  of  only  a  few  lumps  of  dry,  hardened  feces,  were  attended  with 
much  straining. 

Soon  there  followed  a  second  attack  much  more  severe  than  the  first, 
which  was  characterized  by  nearly  similar  symptoms,  only  there  was 
superadded  great  tenderness  over  the  kidneys,  which  were  so  sensitive 
that  the  least  pressure  caused  him  the  most  intense  agony.  The  urine 
was  very  scanty  and  high-colored,  and  there  was  a  well-marked  blue 
discoloration  of  the  gums.  In  a  few  months,  having  somewhat  recovered, 
he  went  to  work  again  at  his  former  occupation,  which  he  pursued  unin- 
terruptedly until  the  25th  of  December,  1869,  when,  after  having  passed 
a  very  uncomfortable  day,  his  former  symptoms  returned  with  increased 
violence,  while  the  paroxysms  of  the  colic  came  on  at  much  shorter  inter- 
vals than  they  had  done  in  the  preceding  seizures;  in  fact,  instead  of 
intermissions  as  formerly,  there  were  only  remissions  of  the  intestinal 
spasm.  For  the  first  time  he  had  pains  in  the  feet  and  the  inside  of  the 
thighs.  The  urine  was  more  scanty  and  higher  colored,  and  the  bowels 
more  constipated  than  before. 

In  three  weeks  he  again  began  to  work,  and  had  no  more  trouble, 
except  constipation  of  the  bowels^  and  weakness  in  both  his  upper  and 
lower  extremities,  until  July,  1870,  when  he  lost  his  appetite,  and  felt 
very  weary  and  exhausted  after  any  small  amount  of  exertion.  He  was 
very  restless  and  could  not  sleep  at  nights,  and  this  inability  to  sleep  was 
a  sequela  of  all  the  other  seizures.  Now  came  great  tremor  of  the  right 
hand  and  arm,  which  was  soon  followed  by  tremor  in  the  left. 

In  August,  1870,  he  had  his  fourth  and  last  attack,  which  was  the  most 
severe  of  all,  and  lasted  about  two  vveeks.  This  time  he  vomited  blood, 
had  acute  pains  in  the  soles  of  his  feet,  and  cramps  in  the  right  hand. 
On  recovering  from  the  effects  of  the  colic  he  found  that  he  was  unable 
to  use  his  arm  or  hand  at  all,  and  that  he  had  lost  power  in  his  legs  also. 

Soon  after  this  he  was  admitted  to  the  Charity  Hospital,  where  he 
remained  for  a  fortnight,  and  during  his  residence  in  that  institution  he 
became  delirious,  and  continued  so  for  about  eighteen  hours.  He  came 
to  the  out-door  department  of  the  New  York  State  Hospital  for  Diseases 
of  the  Nervous  System,  September  12,  1870,  when  his  condition  was  as 
follows:  There  was  the  characteristic  drooping  of  both  wrists,  which  was 
very  extreme  in  degree.  The  paralysis  of  the  supinator  and  extensor 
muscles  of  both  upper  extremities  was  exceedingly  well  marked;  the 
flexors  were  also  involved,  only  to  a  much  more  limited  extent.  The 
paralysis  was  more  considerable  in  the  right  forearm  and  hand  than  in 
the  left.  There  was  much  atrophy  of  all  the  muscles  of  these  parts,  and 
this  was  very  conspicuous  in  the  abductors  and  adductors  of  the  thumbs. 
The  patient  was  so  very  weak  in  his  lower  extremities  that  he  was  unable 
to  arise  from  the  sitting  posture  without  assistance,  and  as  he  walked  he 


FUNCTIONAL    SPASM.  575 

tottered  at  every  step.  Yet  he  did  not  drag  the  toe  of  either  foot,  nor 
Bwing  his  legs,  as  do  those  suiFering  from  hemiplegia.  The  blue  line  was 
very  plainly  seen  around  the  edge  of  the  gums  of  the  upper  and  lower 
jaws.  On  testing  the  amount  of  muscular  power  in  the  right  hand  by 
means  of  the  dynamometer,  he  was  able  to  turn  the  indicator  only  10 
degrees,  while  with  the  left  he  could  accomplish  somewhat  more.  'The 
tactile  sensibility  and  the  sensibility  to  the  electric  current  and  to  pain 
were  very  greatly  diminished.  The  temperature  was  also  diminished  ; 
muscular  contractility  was  so  much  impaired  that  a  powerful  induced 
current  had  not  the  slightest  effect  in  causing  contractions,  and,  even 
when  the  primary  galvanic  current  (sixty  cells  and  very  strong)  was  used, 
the  muscles  responded  very  feebly,  if  we  except,  perhaps,  the  flexors,  so 
almost  completely  had  their  irritability  been  destroyed.  The  bowels  were 
regular,  the  urine  was  normal,  and,  although  no  chemical  analysis  f<ir 
lead  was  made,  undoubtedly  it  would  have  been  found.  "The  appear- 
ance of  the  patient  was  antemic,  cachectic,  and  depressed;  the  breath  was 
very  offensive;  the  retinae  were  anaemic;  the  lungs  were  healthy,  and  so 
was  the  heart,  excepting  an  inorganic  murmur  at  its  base." 

The  treatment  in  this  case  has  consisted  of  the  internal  administration 
of  the  iodide  of  potassium,  commencing  with  ten-grain  doses  three  times 
a  day,  and  the  daily  application  of  the  primary  galvanic  current  to  the 
paralyzed  muscles,  with  a  hypodermic  injection  of  the  thirty-second  of  a 
grain  of  the  sulphate  of  i^trychnia  every  day. 

September  17.  The  iodide  was  increased  to  fifteen  grains  three  times 
a  day. 

2ith.  Slight  fibrillary  contractions  in  the  right  arm  were  produced  to- 
day for  the  first  time  by  means  of  the  faradic  current. 

October  1.  The  iodide  of  potassium  was  increased  to  twenty  grains  three 
times  a  day. 

5th.  The  induced  current  had  just  commenced  to  cause  slight  contrac- 
tions in  the  left  forearm. 

November  15.  Faradization  of  the  left  forearm  produced  good  contrac- 
tions in  the  extensor  carpi  radialis  and  ulnaris  muscles.  The  blue  line 
having  disappeared,  the  iodide  of  potassium  was  discontinued,  and  a  tonic 
substituted. 

23cZ.  The  muscles  of  both  arms  respond  feebly  to  the  induced  current, 
yet  by  means  of  it  the  hands  can  now  be  extended  nearly  on  a  level  with 
the  forearms.  The  right  has  improved  the  most.  Sensibility  to  touch 
and  to  electricity  has  much  improved.  His  bowels  are  regular,  he  sleeps 
well,  and  his  appetite  is  good.  The  power  in  both  hands  is  much  in- 
creased, and  he  is  able  to  work  every  day. 

January  1,  1871.  The  patient  has  almost  entirely  recovered. 

FUNCTIONAL  SPASM. 

Under  this  head  I  propose  to  include  the  various  forms  of  hyperkinesis 
which  depend  upon  irritability  of  the  nervous  centres,  and  which  have 
been  specially  considered,  as  Tetany,  spasm  with  voluntary  movements, 
Reflex  Spasm,  Torticollis,  Professional  Cramp,  etc. 

These  are  generally  due  to  some  peripheral  cause,  or  may  result  from 
overtraining  of  the  automatic  sense,  or  in  certain  conditions  arise  in  a 
manner  which  is  at  present  not  clearly  understood. 


•576  DISEASES    OF    THE    PERIPHERAL    NERVES. 

I.    TETANY. 

A  light  form  of  attack  arising  generally  from  diarrhcea,  cold  and  con- 
stipation, and  sometimes  making  its  appearance  during  lactation.  There 
is  usually  some  formication  of  the  palms  or  soles,  and  an  awkwardness  in 
the  movements  of  the  hands  and  feet,  which  is  afterwards  followed  by  a 
firm  tonic  contraction  of  the  muscles  of  either  of  these  parts.  The  flexors 
are  usually  contracted,  so  that  the  hand  is  curved,  or  all  the  fingers  closed. 
A  more  decided  contraction  may  flex  the  forearm  on  the  arm.  The  foot 
may  be  also  aflfected,  a  condition  of  talipes  resulting,  or  the  back  part  of 
the  leg  may  be  brought  in  apposition  to  the  thigh.  In  marked  forms  the 
upper  and  lower  extremities  are  affected  together,  though  there  is  no  rule 
governing  this,  and  the  spasm  may  be  bilateral  or  unilateral.  The  attack 
rarely  lasts  beyond  an  hour  or  two,  and  in  the  majority  of  in.stances  relax- 
ation may  take  place  in  from  five  to  ten  minutes.  The  spasms  may  come 
on  from  time  to  time,  being  separated  by  greater  or  less  intervals.  They 
are  entirely  uncontrolled  by  the  will,  and  the  patient  cannot  open  his  fin- 
gers when  they  are  thus  contracted.  In  more  severe  forms  the  muscles  of 
the  trunk  or  face  become  involved.  Contraction  of  the  ocular  muscles, 
laryngeal  spasm,  trismus,  or  vesical  spasm  are  examples  of  more  violent 
action.  The  spasms  seem  to  be  produced  when  pressure  is  made  upon  a 
nerve-trunk  or  muscular  belly,  and  there  is  loss  of  tactile  sensibility 
associated  with  neuralgic  pain  in  the  main  nerve  trunk  of  the  convulsed 
limb. 

Tetany  diflfers  from  true  tetanus  from  the  fact  that  the  spasms  aflfect  all 
the  limbs,  that  they  are  intermittent  in  character,  and  that  there  are  in- 
tervals of  relaxation.  Petit-mal  sometimes  resembles  this  condition,  but 
there  is  always  some  loss  of  consciousness. 

II.    FUNCTIONAL  SPASM  WITH  VOLUNTARY  MOVEMENTS. 

MitchelP  reports  some  cases  of  functional  spasm,  which  somewhat  re- 
sembles the  so-called  tetany.  The  spasm  appeared  during  the  exercise  of 
a  voluntary  act;  they  occur  with  the  act  of  laughing,  chewing,  and  talk- 
ing, and  evidently  depend  upon  functional  derangement  of  muscles  inner- 
vated by  the  first  cervical  and  spinal  accessory  nerves.  In  one  case  the 
head  was  drawn  back,  and  the  spine  bowed  so  that  the  patient  was  jerked 
into  a  squatting  posture,  the  gastrocnemius  being  finally  aflTected. 

In  other  cases  the  spasms  occurred  when  the  individual  began  to  walk. 
In  still  other  cases  there  was  a  rhythmical  motion  when  the  patient 
attempted  any  simple  voluntary  action.  These  Weir  Mitchell  called 
"pendulum  spasms,"  the  number  of  twitches  averaging  160  per  minute, 
and  recurring  with  great  regularity. 

Bamberger^  reports  a  case  which  resembled  spasm  of  another  kind, 
Whenever  the  child  was  held  in  the  standing  posture  his  legs  were  drawn 


^  Am.  Journ.  Med.  Sciences,  Oct.  1876.. 

-  Quoted  by  Handfield  Jones,  Functional  Nervous  Disorders. 


REFLEX    SPASM,  577 

up,  and  agitated  by  choreoid  spasms,  the  spine  and  neck  being  twisted 
and  contracted  at  tbe  same  time ;  but  wben  he  was  placed  upon  his  back 
these  movements  ceased. 

III.   REFLEX   SPASM. 

Under  this  head  may  be  classed  a  long  list  of  local  convulsive  move- 
ments dependent  upon  a  variety  of  causes.  Sometimes  there  are  worms 
in  the  intestinal  canal,  and  at  others  a  condition  of  irritability  of  the  geni- 
tals ;  while  peripheral  irritations  of  many  kinds  enter  into  the  etiology  of 
the  spasm. 

I  may  illustrate  the  occurrence  of  one  form  of  spasm  by  the  following 
case  : 

I.  A  boy,  7  years  old,  seen  at  the  request  of  Dr.  Sayre,  was  well 
nourished,  with  rosy  cheeks  and  well-rounded  muscles  of  the  upper  ex- 
tremities. His  morbid  condition  had  existed  from  birth,  and  he  possessed 
a  congenital  phimosis,  the  prepuce  being  firmly  fastened  over  the  glans, 
and  the  preputial  orifice  was  very  small  and  surrounded  by  a  rigid  ring 
of  toughened  skin.  On  entering  the  room  I  was  struck  by  the  extra- 
ordinary restlessness  and  activity  of  the  child.     He  was  lying  on  the 

Fiff.  71. 


Reflex  Spasm  from  Genital  Irritation. 

bed,  and  his  lower  limbs  were  drawn  up  and  agitated  by  irregular  spasms. 
The  arms  were  also  convulsed,  and  their  movements  were  distinctly 
choreic.  When  held  upright  the  child  was  unable  to  stand,  not  from  any 
paresis,  but  from  the  apparent  loss  of  co-ordinating  power,  the  legs  be- 
coming rigid,  and  the  toes  of  both  feet  adducted,  more  particularly  the 
left.  The  child  was  unable  to  speak,  but  attracted  the  attention  of  those 
around  him  by  queer  sounds.  His  face  was  distorted,  just  as  we  often 
see  it  in  old  choreic  patients,,  but  there  was  no  evidence  of  imbecility.  I 
did  not  infer  that  there  was  any  mental  trouble,  except  a  preponderance 
of  emotional  disturbance,  the  boy  being  very  fearful  that  he  was  to  be 
hurt.  Upon  interrogating  I  found  that  he  was  quiet  during  sleep,  that 
his  appetite  was  good,  and  that  there  was  no  irregularity  or  disturbance 
of  the  functions  of  the  bowels  or  bladder.  The  penis  was  not  so  sensi- 
tive as  I  had  expected  to  find  it  from  Dr.  Sayre's  description  of  previous 
cases.  Titillation  did  not  produce  immediate  erection,  nor  any  increase 
of  the  spasmodic  movements.  On  taking  him  upon  my  lap  the  thighs 
and  legs  were  immediately  drawn  up ;  there  was  no  evident  pain  pro^ 
duced  by  pressure  on  the  spine. 
37 


578  DISEASES    OF    THE    PERIPHERAL    NERVES. 

A  form  of  reflex  spasm  of  the  eyelids  was  reported  by  Von  Griiefe/ 
which  rendered  the  patient  helpless,  for  he  was  unable  to  go  about  alone. 
There  was  no  pain  produced  on  pressure  in  the  course  of  the  fifth  nerve  ; 
but  when  pressure  was  made  on  the  glosso-palatine  arch  on  the  left  lower 
jaw,  the  spasm  ceased  at  once,  and  the  patient  could  open  his  eyes.  A 
putrid  ulcer  was  found  at  this  locality,  which  acted  as  a  centre  of  irrita- 
tion upon  the  gustatory  nerve. 

IV.   FACIAL   SPASM  WITHOUT   PAIN. 

A  form  of  facial  spasm  not  connected  with  voluntary  motorial  move- 
ment is  occasionally  met  with,  the  orbicularis  palpebrarum  or  buccinator 
being  affected  alone,  or  all  the  muscles  of  the  face  supplied  by  the  portio 
dura  being  convulsed.  The  trouble  differs  from  epileptiform  tic  for  the 
reason  that  it  is  unaccompanied  by  pain.  I  have  been  so  fortunate  as  to 
see  two  of  these  cases.  One  was  that  of  a  gentleman  aged  56,  who  suf- 
fered an  almost  constant  spasm  of  the  orbicularis  of  the  eye,  which  was 
always  increased  when  he  was  fatigued.  The  eye  would  become  red,  and 
there  .was  usually  a  discharge  of  tears,  which  were  unable  to  find  their 
way  into  the  lachrymal  duct,  and  consequently  ran  on  the  cheek.  Cases 
of  unilateral  painless  spasm  have  been  reported. 

V.   TORTICOLLIS. 

The  sterno-cleido  mastoid  muscle  may  be  the  seat  of  a  spasmodic  con- 
traction. This  condition  may  be  preceded  by  peripheral  trouble,  such  as 
painful  dentition,  which  was  the  cause  in  one  of  Romberg's  cases,  or  by 
such  general  disease  as  rheumatism.  One  case,  which  was  seen  by  Dr. 
White  and  myself,  was  preceded  by  chorea,  and  another,  that  I  saw  at  the 
New  York  State  Hospital  for  Diseases  of  the  Nervous  System,  was  due  to 
general  anremia.  In  both  these  cases,  as  well  as  in  others  I  have  ob- 
served the  head  was  bent  forward  and  the  chin  pulled  downward.  In 
one  case,  that  of  the  elderly  woman  at  the  Hospital,  the  spasms  were  in- 
termittent. Radcliffe  reports  a  case  which  somewhat  resembles  this.  The 
muscles  of  the  neck  were  tender  and  the  seat  of  soreness,  and  the  move- 
ments Avere  attended  by'pain.  The  spasms  are  usually  increased  by  emo- 
tional excitement,  but  subside  during  sleep.  The  notes  of  my  case  are  the 
following: — 

M.  A.  A.,  aged  56,  U.  S.  Came  to  the  hospital  Oct.  29,  1872.  Her 
present  trouble  began  five  years  ago  in  a  very  gradual  manner.  There 
are  now  marked  clonic  spasms  of  the  muscles  of  the  anterior  part  of  the 
left  side  of  the  neck.  With  their  intermitting  contraction,  there  is  some 
pain  at  the  lower  insertion  of  the  sterno-cleido-mastoideus  muscle  ;  the 
trapezius  is  also  the  seat  of  spasmodic  contraction.  There  is  headache, 
and  pain  at  the  upper  part  of  the  cord.  Patient's  expression  anxious  and 
excited.  Galvanism  to  muscles  and  spine,  and  zinci  phosphidi  gr.  i  t.  i. 
d.     Patient  complains  of  dizziness  and  constipation. 

1  Schmidt's  Jahresbericht,  vol.  127,  p.  30 ;  reported  by  H.  Jones,  p.  390. 


T0ETIC0LLI8.  579 

The  muscles  concerned  in  this  form  of  disease  are  the  stemo-cleido- 
mastoideus,  complexus,  trapezius,  and  levator  anguli  scapulse. 

Pathology.— Weir  Mitchell  has  divided  the  conditions  under  which 
spasms  of  this  kind  may  occur  into  three  groups  : — 

1.  "  Those  in  which  the  functional  activity^of  a  muscle  or  set  of  muscles 
gives  rise  at  times  to  an  exaggeration  of  the  motion  involved  naturally, 
and  sometimes  also  to  a  more  or  less  spasmodic  activity  in  remoter 
groups. 

2.  "  Those  in  which  the  functional  action  of  one  group  results  only  in 
sudden  and  possibly  in  prolonged  acts,  tonic  or  clonic,  in  remote  groups 
of  muscles  not  implicated  in  the  original  movement. 

3.  "  Those  in  which  standing  or  walking  occasions  general  and  disor- 
derly motions  affecting  the  limbs,  trunk,  face,  and  giving  rise  to  a  general 
and  uncontrollable  spasm  without  loss  of  consciousness." 

The  central  condition  is  one  of  great  reflex  irritability  ;  certain  forms 
of  repeated  irritation  producing  an  activity  of  the  motor  centre  which  re- 
sults in  an  abnormal  increase  in  reflex  susceptibility. 

Treatment. — Agents  which  lower  the  excitability  of  voluntary  mus- 
cular action  are  to  be  adopted.  Among  these  hyoscyamia,  gelseminum, 
musk,  ether  and  assafoetida  are  efficient  when  used  cautiously.  Rest,  and 
removal  of  the  peripheral  irritation,  should  the  spasm  be  of  reflex  origin, 
and  the  ether  spray  to  the  spine,  are  to  be  resorted  to  ;  and  at  the  same 
time  various  measures  which  improve  the  individual's  general  condition 
are  in  order.  If  all  of  these  drugs  I  have  mentioned  be  powerless  to 
subdue  the  excitable  condition  of  the  muscles,  I  prefer  profound  bro- 
minization,  which  sometimes  controls  the  movements.  Myotomy  in  tor- 
ticollis has  not  proved  itself  to  be  a  successful  operation,  and  so  I  do  not 
recommend  it.  In  other  conditions,  such  as  adherent  prepuce,  an  opera- 
tion is  the  only  method  that  promises  a  cure. 

The  use  of  electricity  in  spasmodic  afiections  is  to  be  resorted  to  as 
promptly  and  thoroughly  as  possible.  In  torticollis  it  has  hitherto 
been  only  moderately  beneficial. 

The  lack  of  uniform  success  in  the  cases  reported  and  a  realization  of 
the  fact  that  electricity  is  of  such  great  use  in  so  many  other  spasmodic 
affections  leads  me  to  believe  that  many  more  patients  might  be  relieved 
if  the  treatment  were  directed  with  a  view  to  meet  the  pathological  indi- 
cations, which  aftei^  all  seem  plain  enough.  In  the  early  stages,  it  appears 
that  the  anterior  muscles  of  the  neck  are  not  primarily  affected,  but 
rather  the  trapezius,  and  at  such  a  stage  the  electrization  of  the  sterno- 
mastoideus  seems  unwise.  In  other  cases  the  approximative  galvanization 
of  the  spinal  accessory  is  indicated,  while  in  the  confirmed  cases,  which 
by  the  way  we  see  the  most  of,  I  am  about  to  speak  of  a  treatment  which 
I  am  not  aware  has  been  described  heretofore.  I  find  no  allusion  to  the 
simultaneous  employment  of  the  two  currents  for  the  production  of  their 
physiological  effects. 

In  the  early  part  of  1879  my  attention  was  first  called  to  their  use  by 
a  patient  who  had  been  under  the  care  of  my  friend  Dr.  Findlay,  of  Ha- 


580  DISEASES    OF    THE    PERIPHERAL    NERVES. 

vana,  and  who  had  been  greatly  relieved.  Knowing  nothing  of  Dr. 
Findlay's  plan  of  treatment,  I  began  a  series  of  experiments  to  determine 
the  best  form  of  application  and  electrode,  and  after  some  trouble  devised 
a  method. 

An  electrode  was  constructed,  which  is  armed  with  two  sponge-covered 
pads,  one  of  Avhich  is  connected  with  the  positive  pole  of  a  galvanic  bat- 
tery of  twenty  cells,  while  the  other  is  attached  to  the  negative  wire  of  an 
induction  coil.  The  double  electrode  is  to  be  applied  at  the  back  of  the 
neck,  the  two  plates  forming  the  terminal  ends  of  the  galvanic  and  fara- 
daic  apparatus,  and  being  insulated  by  a  central  plate  of  hard  rubber. 
Any  ordinary  double  electrode  may  be  used,  however,  and  will  answer 
every  purpose.  The  negative  galvanic  electrode  is  to  be  placed  over  the 
insertion  of  the  sterno-cleido-mastoid  muscle  of  the  affected  side,  so  that  a 
descending  current  is  sent  through  the  contracted  muscle,  while  upon  the 
insertion  of  the  muscle  of  the  other  side  is  placed  a  sponge-covered  elec- 
trode attached  to  the  positive  wire  of  the  induction  coil.  The  antagonistic 
muscle  is  thereby  subjected  to  the  stimulation  of  an  ascending  current 
from  the  faradaic  apparatus. 

Fiff.  72. 


The  treatment  of  these  cases  is  suggested  entirely  by  the  physiological 
influence  of  the  two  currents  upon  muscular  tissue.  In  wry-neck  of  the 
spastic  variety  there  is  of  course  on  one  side  a  condition  of  tonic  spasm, 
while  on  the  other  side  the  antagonistic  muscle  is  necessarily  in  a  condition 
of  lowered  tone,  subjected  as  it  is  to  the  strain  imposed  by  the  position  of 
the  head  and  by  the  unavoidable  traction.  It  will  be  seen  that  the  con- 
dition of  the  antagonist  is  worse  even  than  that  of  an  opposing  muscle 
in  some  other  part  of  the  body  where  there  is  less  mechanical  strain  or 
tension  o£  parts,  as  in  this  case  the  weight  of  the  head  is  a  factor  in  the 
disease  which  prevents  the  opposing  muscle  from  ever  being  properly 
subjected  to  the  improving  influence  of  treatment. 

A    paralysis    unaccompanied    by    contractures,    and    consequently 


TORTICOLLIS.  581 

with  no  permanent  stretching  of  opponents  is,  as  we  well  know,  much 
more  readily  improved  by  electricity  if  the  strain  be  removed  by  proper 
appliances — such,  for  instance,  as  the  apparatus  devised  by  Van  Bibber 
and  Detmold  for  lead  and  facial  paralysis.  In  the  case  of  wry-neck,  it 
must  be  borne  in  mind  that,  as  no  apparatus  can  be  suggested  which  will 
do  more  than  tire  out  the  vicious  spasm  of  the  contracted  sterno-cleido- 
mastoideus  (a  therapeutical  measure  which  I  consider  to  be  unphysiolog- 
ical,  from  the  fact  that  the  spasm  is  an  evidence  of  deficient  or  irregular 
innervation),  a  procedure  which  will  tend  to  diminish  the  irritability  of 
the  muscle  in  spasm,  while  increasing  the  energy  and  improving  the  nu- 
trition of  the  weakened  opponent,  is  by  far  preferable. 

In  many  cases,  I  am  convinced,  there  is  an  hysterical  element,  which 
is  decidedly  increased  by  forcible  restraint ;  and  that  this  feature  of  the 
trouble  belongs  both  to  men  and  to  women,  I  have  no  doubt.  It  is  not  diffi- 
cult to  imagine  that  harsh  or  irritating  treatment  will  do  harm  in  such  cases. 

In  the  varieties  of  wry-neck  connected  with  disordered  movements, 
there  are  several  methods  of  treatment  in  vogue,  which  are  sometimes 
successful.  The  ether-spray,  either  mediate  or  immediate  (in  the  one  case 
applied  to  the  back  of  the  neck  ;  in  the  other,  to  the  muscles  themselves 
for  five  minutes  at  a  time),  does  good  in  some  cases.  In  other  cases  the 
local  injection  of  sulphate  of  atropia  will  markedly  modify  the  spasm, 
while,  in  cases  of  great  severity,  decided  doses  of  the  tincture  of  gelseminum 
sempervirens  or  of  hyoscyamia  will  diminish  the  violence  of  the  spasmodic 
condition.  A  case  mentioned  by  Radcliffe  was  treated  with  hypodermic 
injections  of  Fowler's  solution,  and  improved  somewhat. 

While  I  am  not  disposed  to  take  the  grave  view  of  the  prognosis  ex- 
pressed by  Reynolds,  it  must  be  confessed  that  there  are  very  many  ex- 
amples which  are  not  permanently  benefited.  Under  this  head  come 
those  which  are  unquestionably  varieties  of  spinal  or  cerebral  sclerosis. 
I  have  seen  a  case  of  progressive  muscular  atrophy  which  had  been  mis- 
taken for  wry-neck.  In  cases  of  organic  disease  of  the  brain,  the  early 
history  of  the  case  and  the  connection  perhaps  with  paralysis  or  contracture 
of  the  extremities  show  us  that  the  case  is  not  one  of  true  torticollis.  Ex- 
ceedingly rare  cases  of  tonic  contraction  are  met  with  in  which  the  essen- 
tial condition  is  dislocation  or  disease  of  the  cervical  vertebrse.  Then,  of 
course,  the  prognosis  is  bad. 

The  cases  most  readily  helped  are  those  dependent  upon  rheumatism  or 
hysteria,  and  in  such  the  prognosis  is  highly  favorable.  In  the  latter 
form  of  trouble,  one  or  two  applications  of  the  faradaic  current  are  alone 
sufficient,  and,  if  the  diagnosis  is  certain,  it  will  be  found  that  a  shower 
of  sparks,  derived  from  a  Holtz  machine,  directed  upon  the  muscle,  will 
favor  a  sudden  disappearance  of  the  spasm. 

A  case  of  clonic  spasm  of  the  facial  muscles  of  a  very  serious  and  per- 
sistent nature  was  cured  by  Baum,  by  nerve  section.  A  slight  paralysis 
of  half  an  hour's  duration  was  produced.^ 

1  Berliner  Klin.  Woch.,  1878,  No.  40,  and  Bost.  Med.  and  Surg.  Journal,  Sept.  4, 
1879,  p.  341. 


582  DISEASES    OF    THE    PERIPHERAL    NERVES. 


PROFESSIONAL  CHAMP. 

Synonyms. — Writer's  cramp,  Dancer's  cramp,  Telegrapher's  cramp ; 
Dyskinesie  professiouelle ;  Melker-krampf,  Schuster-krampf,  Niihckrampf. 

This  very  interesting  condition,  which  follows  the  overtraining  of  groups 
of  muscles,  is  found  among  all  who  engage  in  occupations  which  require 
the  exercise  of  particular  voluntary  muscles  of  the  upper  and  lower  ex- 
tremities to  an  excessive  degree.  Among  these  individuals  such  pro- 
tracted muscular  action,  especially  when  of  a  delicate  kind,  is  likely  to  be 
followed  by  spasmodic  movements  such  as  would  come  under  the  first 
group  of  Mitchell. 

It  is  the  first  of  the  above  varieties  that  at  present  interests  us  the 
most. 

Writer's  Cramp  is  the  form  of  hyperkinesis  with  which  we  are  the 
most  familiar,  and  it  is  difficult  to  fail  in  recognizing  its  true  character. 
After  continued  and  fatiguing  use  of  the  pen  the  hand  may  become  at 
first  tired ;  afterwards  the  patient  suffers  from  sharp  pains  which  run 
from  the  hand  up  the  arm,  while  dull  pains  seated  in  the  ball  of  the 
thumb,  the  dorsal  aspect  of  the  lingers,  the  wrist,  or  at  the  exposed  por- 
tion of  the  ulnar  nerve  at  the  elbow,  are  to  be  found  as  well.  His  first 
intimation  may  be  a  certain  tired  feeling,  or,  as  a  very  intelligent  patient 
under  my  e.are  expressed  it,  "  The  first  idea  of  my  trouble  came  from  the 
feeling  that  I  had  an  arm.  My  mind  was  directed  to  it,  and  whether 
resting  or  at  work,  it  felt  like  a  clumsy  part  of  my  body."  If  the  indi- 
vidual carefully  forms  his  words,  or  if  he  "  writes  with  his  fingers  " — a 
habit  which  schoolboys  have,  and  which  sometimes  continues  through 
life — the  trouble  is  much  more  probable  than  when  he  uses  his  whole 
hand  in  guiding  his  pen.  He  may  find  after  a  while  that  when  he  at- 
tempts to  write,  the  hand  will  fly  ujjwards  as  the  result  of  a  spasm  of  the 
extensors  and  other  muscles  on  the  dorsal  and  ulnar  side  of  the  forearm, 
so  that  it  is  often  impossible  to  form  more  than  one  or  two  words  of  a 
note  before  the  trouble  begins. 

This  impaired  writing  power  may  exist  to  a  lighter  degree;  but  when  the 
individual  persists  in  his  attempts,  the  convulsion  is  certain  to  take  place. 
A  light  tonic  spasm  of  the  abductor  mimimi  digiti  may  occur  when  the 
little  finger  is  separated  from  its  felloAvs,  and  this  is  sometimes  an  early 
sign  of  the  disease.  He  may  educate  the  left  hand  to  do  the  work  of  the 
right,  and  after  a  while  may  learn  to  use  it  in  a  satisfactory  manner  ;  but 
very  soon  this  too  becomes  affected,  and  he  can  write  with  neither  hand. 
Other  muscular  movements  are  freely  performed,  and  even  some  which 
closely  resemble  that  of  holding  the  pen.  Trembling  sometimes  super- 
venes, while  fibrillary  muscular  contractions  are  suggestive  of  the  con- 
firmed disease.  As  is  the  case  in  sclerosis,  the  disorderly  movements,  or 
the  spasms,  seem  to  be  intensified  when  the  patient  attempts  to  write  in 
the  presence  of  a  looker-on,  and  he  usually  makes  sad  work. 


PROFESSIONAL    CRAMP.  583 

The  fingers,  forearm,  and  wrist  sometimes  become  the  seat  of  lost 
power,  and  this  is  marked  in  the  three  first  fingers  of  the  right  hand,  and 
the  pronators  and  supinators  lose  power.  Sensation  is  rarely  lost  or  im- 
paired. In  some  cases  the  flexors  of  the  hand  and  the  small  muscles  of 
the  thumb  are  so  weak  that  the  point  of  the  pen  cannot  be  kept  in  contact 
with  the  paper,  as  the  extensors  seem  to  act  independently. 

The  same  form  of  cramp  affects  the  thumbs  and  fingers  of  telegraphers, 
so  that  their  work  eventually  becomes  an  impossibility.  Onimus^  pre- 
sents a  case.  A  telegraphic  operator,  19  years  of  age,  first  experienced 
difficulty  in  making  dots;  "  d"  was  made  better  than  "u;"  and  it  was 
found  that  when  a  line  was  first  the  dots  were  more  easily  made ;  but  let- 
ters like  "  h  "  or  "  p  "  were  exceedingly  difficult.^ 

Dancers'  cramp  has  also  been  observed.  Schultz^  describes  this  form 
of  disease,  of  which  he  has  seen  three  cases.  It  affects  the  solo  dancers  of 
the  ballet  as  a  rule,  and  the  history  of  one  case  was  the  following : — 

"  The  patient  complained  of  suffering  very  severe  pains  while  dancing. 
Beginning  in  the  soles  of  both  feet,  the  pains  spread  with  increasing 
severity  to  the  calves  of  the  legs  ;  they  at  last  became  so  violent  that  her 
feeling  of  security  was  lost,  the  feet  seeming  as  if  made  of  wood.  These 
pains  were  accompanied  with  violent  palpitation ;  and,  if  she  continued  to 
dance,  she  felt  faint  and  sometimes  lost  consciousness,  the  body  becoming 
quite  rigid.  When  the  pain  and  palpitation  were  less  intense,  the  pain 
continued  after  dancing,  and  ceased  very  gradually,  leaving  some  tender- 
ness of  the  soles ;  on  attempting  again  to  dance  the  suffering  would  recur 
again.  Dr.  Schultz  found,  from  the  examination  of  these  cases,  that  the 
cause  of  pain  lay  in  the  pas  performed  on  the  points  of  the  feet,  and  is 
owing  to  exhaustion  of  the  muscles  which  fix  the  metatarsus  and  pha- 
langes of  the  great  toe.  The  shoe  worn  by  the  dancer,  without  which  the 
ballet  step  seems  to  be  impossible,  is  made  as  follows  :  The  dancing-shoe 
is  made  rather  wide;  the  sole  is  of  soft  leather,  and  shorter  than  the  foot, 
reaching  only  as  far  as  the  posterior  third  of  the  ungual  phalanx  of  the 
great  toe.  The  upper  part,  generally  of  satin,  projects  forward,  and  sup- 
plies the  place  of  the  deficient  leather  of  the  sole.  This  part  of  the  satin 
is  worked  threads,  so  that  it  may  not  be  torn.  In  the  interior  of  the 
shoe,  over  the  leather  sole,  is  a  layer  of  thin,  firmly-pressed  pasteboard, 
either  extending  over  the  whole  breadth  of  the  anterior  part,  or  limited 
to  the  length  of  the  great  toe.  In  the  former  case  it  is  carried  back, 
gradually  narrowed  as  far  as  the  heel.  The  leather  sole  and  its  cover- 
ing are  lined  with  fine  kid  leather.  The  heel  part  of  the  shoe  is  quite 
soft,  consisting  only  of  satin  ;  and  the  shoe  is  fastened  above  the  ankle 
by  narrow  ribbons.  Without  this  preparation  the  pointed  step  is  im- 
possible." 

I  have  met  with  the  aflfection  among  violin-players,  and  within  the  past 
year  have  had  a  patient  under  treatment.  He  had  been  diligently  prac- 
tising a  "  run,"  which  involved  the  necessity  of  complicated  movements  of 

^  Gaz.  Med.  de  Pari? ;  Chicago  Journal  of  Mental  and  Nervous  Diseases,  July, 
1875. 
a  ( u)  ( d)  ( h  ; p.)  ^  Wiener  Med.  Woch. 


584  DISEASES    OF    THE    PERIPHERAL    NERVES. 

the  fingers ;  and  it  was  bis  custom,  on  arising  in  the  morning,  to  spend  a 
half  hour  or  so  in  playing  the  difficult  passage;  and  on  the  day  of  the 
concert  he  worked  for  several  hours  at  the  same  task,  but  upon  attempt- 
ing to  play  in  the  evening  he  found  it  utterly  impossible  to  do  so,  as  his 
fingers  would  become  rigid  and  refuse  to  obey  the  will.  It  was  some 
months  before  he  could  again  play. 

Onimus,'  in  describing  a  form  of  impaired  power  and  consequent  mus- 
cular atrophy,  which  he  calls  "  professional  muscular  atrophy,"  details  a 
case  which  resembles  somewhat  the  form  of  functional  disease  which  we 
are  considering.  It  begins  by  muscular  cramp,  and  there  is  subsequent 
loss  of  power  with  wasting.  I  therefore  think  we  may  consider  this  affec- 
tion as  a  connecting  link  between  scrivener's  cramp  and  progressive  mus- 
cular atrophy.    He  says  : — 

"  Recently  I  observed  one  case  which  it  was  most  difficult  to  diflTeren- 
tiate  from  progressive  muscular  atrophy,  as  the  ati'ophied  muscles  were 
the  same  as  those  which  are  the  first  affected  by  this  latter  affection. 
They  were  the  muscles  of  the  thenar  eminence,  and  chiefly  the  adductor 
pollicis.  The  patient  was  an  enameller,  who  had  to  hold  an  object  all 
day  between  his  thumb  and  index  finger.  He  first  got  cramps  in  the 
thumb,  which  suggested  the  idea  of  scrivener's  palsy  ;  then  tremor  of  the 
thumb,  on  account  of  the  fibrillary  contractions ;  and,  lastly,  atrophy. 
Under  the  influence  of  treatment  there  was  a  rapid  amendment,  which 
showed  that  the  case  was  really  one  of  professional  muscular  atrophy,  and 
not  commencing  progressive  atrophy." 

Causes  and  Pathology. — This  spasmodic  affection  follows  the  con- 
tinued use  of  the  muscles  which  are  concerned  in  delicate  muscular  ac- 
tions ;  and  is  not  only  produced  by  writing,  but,  as  I  have  shown,  by 
other  forms  of  manipulation  requiring  great  delicacy  of  co-ordination. 
The  higher  and  the  more  complex  is  the  character  of  these  acts,  and  the 
more  easily  the  faculty  to  perform  them  becomes  developed,  so  much  the 
greater  is  the  danger  of  the  disease.  An  act  which  requires  at  first  men- 
tal direction  of  a  superior  kind,  when  acquired  and  executed  uncon- 
sciously, is  much  more  likely  to  give  rise  to  this  neurosis  than  one  of  a 
grosser  kind,  or  one  which  is  constantly  performed  under  the  active 
direction  of  the  will.  For  this  reason  writer's  cramp  is  much  more  rare 
among  those  who  write  and  meanwhile  compose,  than  among  clerks  or 
copyists  who  do  "  machine  work."  Constant  use  of  the  pen  of  this  kind 
is  seen  to  be  followed  by  mischief.  Such  causes  as  piano-playing  or  violin - 
playing  are  by  no  means  rare.  A  young  lady,  sent  to  me  by  my  friend 
Dr.  D.  M.  Stimson,  owed  all  her  trouble  to  a  bad  habit  she  had  contracted 
of  reading  novels  while  she  practised  her  scales.  In  her  case  there  was 
extensor  paralysis,  and  some  loss  of  sensation,  which  remained  after  a 
spasmodic  stage. 

The  conditions  then,  with  the  exception  of  paralysis,  are  the  result  of 
an  over-developed  automatism,  and  are  not,  I  am  convinced,  connected 

1  London  Lancet,  Jan.  22,  1876. 


PROFESSIONAL    CRAMP.  585 

with  any  central  change,  though  Mr.  Solly  ^  is  inclined  to  consider  that 
there  is  degeneration  of  the  motor  cells  in  the  upper  part  of  the  cord. 

In  writing  a  familiar  word,  or  collection  of  words,  the  educated  indi- 
vidual does  not  stop  to  form  every  letter,  but  the  pen  is  unconsciously 
guided.  It  is  even  possible  to  talk  while  writing  or  playing  the  piano, 
and  equally  complex  feats  are  performed  while  the  mind  is  not  engaged. 
In  many  of  these  acts  the  volition  is  directed  in  other  channels,  or  is 
behind  the  muscular  action.  The  pen  travels  in  advance  of  the  mind; 
and  should  this  state  of  things  be  so  exaggerated  as  to  become  more  than 
a  phase  of  the  ordinary  automatism  which  enters  into  the  performance 
of  many  of  the  functions  of  daily  life,  there  remains  condition  of  dis- 
ordered and  heightened  activity  which  is  uncontrolled  by  the  will,  and  is 
symptomatized  by  the  spasms  of  which  I  have  spoken,  A  more  advanced 
condition  consists  in  exhaustion  of  the  motor  cells  at  the  upper  part  of 
the  cord,  and  as  a  result  we  find  loss  of  power  and  occasionally  atrophy. 
Poore^  dues  not  believe  in  the  central  organic  origin  of  the  disease;  but 
Solly,'  Smith,*  and  others  take  this  view  of  the  case. 

Among  24  cases  which  I  have  seen,  the  occupation  of  the  individuals 
was  as  follows: — 


Clerks     . 

.     14 

Stenographer     . 

.       .     1 

Engraver 

.        .      1 

Musicians  . 

.       .    3 

Lawyers 

.       .      2 

Type-setter 

.      .     1 

Clergymen     . 

.      1 

Cigar-maker 

.      .    1 

The  patients  were  all  men  but  one,  and  with  this  exception  were  be- 
tween the  ages  of  30  and  60 ;  I  do  not  believe,  however,  this  latter  fact 
has  very  much  importance. 

Diagnosis. — Progressive  muscular  atrophy  may  be  mistaken  for  the 
paralytic  form,  but  when  it  is  remembered  that  the  paralysis  precedes 
the  atrophy  (should  such  tissue-change  take  place),  and  that  progressive 
muscular  atrophy  is  rarely  so  limited,  there  is  no  reason  why  the  real 
nature  of  the  trouble  should  not  be  recognized.  Neuralgia  of  the  cervi- 
co-brachial  variety  is  a  common  symptom,  and  its  real  significance  may 
not  be  detected ;  the  subsequent  element  of  spasm,  tremor,  or  paralysis 
will,  however,  remove  any  doubt  from  the  mind  of  the  observer. 

Prognosis. — If  the  individual  gives  up  the  occupation  which  has 
produced  the  afiection,  there  is  no  reason  why  he  should  not  recover, 
provided  the  disease  has  not  become  confirmed,  and  even  in  this  form 
Jaccoud^  speaks  of  a  rare  temporary  amelioration.  It  has  been  my 
experience  that,  if  taken  in  hand  promptly,  the  patient  may  be  cured. 
Sixteen  of  these  cases  were  absolutely  cured,  and  continued  so  as  long  as 

>■  Surgical  Experiences,  London,  1865,  p.  205. 
2  Practitioner,  .June,  July,  and  August,  1873. 
5  Op.  cit. 

*  Lancet,  March  27,  1869. 

*  Op.  cit.,  p.  302. 


586  DISEASES    OF    THE    PERIPHERAL    NERVES. 

they  refrained  from  their  work.  Two  were  improved,  but  upon  begin- 
ning the  pursuit  of  tbeir  calling  bad  relapses.  The  remainder  were  of 
the  paralytic  variety,  and  have  been  for  some  time  under  treatment. 

Treatment. — Rest  and  electricity  are  the  means  at  our  command. 
A  galvanic  current  is  found  to  be  the  most  beneficial,  and  the  electrodes 
should  be  so  small  as  to  include  but  one  muscle  at  a  time  in  the  circuit. 
The  current  must  be  mild,  or  it  will  only  aggravate  the  disease.  Besides 
this  application  to  special  muscles,  one  pole  may  be  placed  at  the  nape  of 
the  neck,  and  the  other  to  the  muscles  of  the  hand  and  forearm. 

A.  W.,  aged  38.  The  patient  had  followed  the  occupation  of  clerk  for 
several  years,  and  had  assiduously  worked  at  his  desk  for  many  hours 
in  the  day.  Two  weeks  before  I  saw  him  he  noticed  an  impairment  in 
his  writing  power,  and  this  consisted  in  an  inability  to  write  without  the 
occurrence  of  a  convulsive  contraction  of  the  extensors  of  his  right  fore- 
arm, by  which  the  pen  flew  from  the  paper.  This  did  not  occur  at  the 
moment  of  writing,  but  after  a  few  words  had  been  finished.  He  tried 
to  keep  the  hand  steady  by  the  influence  of  the  will,  but  all  his  efforts 
were  ineffectual.  When  he  attempted  to  hold  the  point  of  any  small  ob- 
ject, such  as  a  stick  or  pencil,  against  the  surface,  the  same  spasm  would 
occur.  There  was  no  wasting  of  the  muscles,  pain,  or  other  symptom. 
I  determined  to  try  galvanism  combined  with  manual  exercise,  and  the 
internal  application  of  strychnia  in  doses  of  ^ith  of  a  grain.  Galvaniza- 
tion of  the  flexors  of  the  forearm  and  of  the  small  muscles  of  the  hand 
was  made,  and,  at  the  same  time,  the  positive  pole  was  held  for  a  few 
minutes  at  the  nape  of  the  neck.  He  was  directed  to  procure  the  rounds 
of  a  chair  with  which  to  exercise.  Galvanization  was  persevered  in, 
although  the  progress  was  very  slow.  At  first  he  could  not  write  more 
than  two  words  (almost  illegibly) ;  but  as  he  grew  better,  these  spasms 
disappeared. 

Three  seances  a  week  kept  up  for  a  period  of  about  three  months  effect- 
ed such  an  improved  condition  that  he  was  finally  discharged  at  the  end 
of  that  time. 

Strychnia  and  iron,  or  conium,  are  remedies  which  may  be  used  in 
conjunction.  The  ether  spray  apparatus  does  great  good,  and  I  have 
occasionally  benefited  my  patients  by  fastening  the  hand  in  an  immova- 
ble apparatus  or  sjDlint.  Absolute  cessation  of  the  particular  work  which 
gave  rise  to  the  malady  is  to  be  inskted  upon,  and  no  benefit  will  result 
from  any  form  of  treatment  unless  this  command  of  the  physician  is 
r  espected. 

When  the  patient  attempts  writing  anew  he  should  provide  himself 
with  a  pen  having  a  cork  holder,  and  this  may  be  purchased  from  any 
good  stationer.  He  should  change  his  system  of  penmanship  and  acquire 
the  so-called  free  hand  style,  in  which  the  fingers  are  engaged  only  in 
holding  the  jjen,  and  the  other  motions  are  performed  by  the  muscles  of 
the  forearm.  The  attempt  at  "  shading "  the  lines  should  not  be  made 
but  he  should  endeavor  to  adopt  the  round  hand  and  avoid  "pot  hooks" 
and  "up  and  down"  strokes  as  much  as  possible. 


GESOPHAGISMUS.  587 

Sea  air,  salt  baths,  and  a  change  of  habits  and  scene  are  all  fraught 
■with  benefit. 

I  do  not  consider  tenotomy  advisable  except  in  extreme  instances. 

GESOPHAGISMUS. 

A  comparatively  rare  neurosis  often  met  with  among  women  consists  in 
a  spasmodic  contraction  of  the  oesophagus.  It  is  usually  hysteroid  in 
character,  or  may  be  the  reflex  result  of  a  simple  stomatitis,  beginning, 
perhaps,  in  a  trivial  irritation  of  the  food  passage ;  and  giving  the  indivi- 
dual little  annoyance  at  first,  it  may  develop  into  a  condition  causing 
great  misery  and  sufifering  from  dysphagia,  so  that  she  may  be  unable  to 
swallow  anything  but  fluids,  and  these  in  small  quantities,  and  most 
easily  when  they  are  warm. 

"  Tightness  of  the  throat,"  the  globus  hystericus  and,  more  or  less, 
hypersesthesia,  may  be  symptoms  which  precede  or  accompany  the 
trouble. 

There  is  emotional  derangement  as  well,  and  the  patient  weeps  and  is  de- 
spondent. The  symptoms  of  spinal  irritation  may  or  not  be  manifested, 
and  there  is  usually  some  spinal  tenderness.  A  patient  sent  to  me  by  Dr. 
Cohen,  of  Philadelphia,  had  suffered  for  several  years,  and  I  have  exa- 
mined other  patients  who  have  suffered  even  longer.  The  discomfort  at- 
tending the  local  trouble  affects  the  general  condition,  and  malnutrition 
from  insufficient  food  and  sleeplessness  reduce  the  patient  in  every  way. 
An  examination,  by  means  of  an  olive-pointed  bougie,  will  immediately 
apprise  us  of  the  cause  of  the  annoyance,  and  among  hysterical  women, 
who  complain  of  their  inability  to  swallow,  we  will  often  find,  by  local 
examination,  that  there  is  a  true  oesophageal  spasm,  which  is  sufficient  to 
account  for  the  subjective  expressions  some  of  us  are  inclined  to  disre- 
gard. 

I  have  met  with  subjects  who  complained  of  a  spasm  of  the  upper 
part  of  the  pharynx  with  sharp  pain,  and  in  several  instances  have  traced 
its  origin  to  the  immoderate  use  of  tobacco. 

Treatment. — The  affection  is  a  troublesome  and  persistent  one. 
Galvanization  of  the  sympathetic  ;  local  treatment  by  bougies  and  ether 
spray  to  the  back  of  the  neck  are  important  external  remedies  ;  while  we 
may  give  internally,  hysocyamia  or  any  of  the  anti-spasmodics  before 
alluded  to. 


THE   END. 


INDEX 


ABORTED  epilepsy,  390 
Abscess  of  cerebellum,  229 
Absence  of  blood  in  cutaneous  vessels  in 

hysteria,  457 

of    "tendon    reflex"    in    locomotor 
ataxia,  322 
Abstinence  from  food  in  hysteria,  461 
Abuse  of  bromides  in  epilepsy,  408 
Active  cerebral  hypersemia,  76 
Acute  alcoholism,  430 

cerebral  anaemia,  127 

cerebritis,  165 

myelitis,  265 

softening,  164 
Acute  ascending  paralysis,  275 

synonyms  of,  275 

definition  of,  275 

symptoms  of,  275 

causes  of,  276 

pathology  of,  276 

diagnosis  of,  277 

prognosis  and  treatment  of,  277 
Acute  cerebral  meningitis,  48 

symptoms  of,  48 

causes  of,  49 

pathology  and  morbid  anatomy  of,  50 

prognosis  and  treatment  of,  54 
Acute  granular  (tubercular  meningitis),  58 

symptoms  of,  58 
Acute  and  chronic  spinal  meningitis,  236 

symptoms  of,  236 

causes  of,  240 

morbid  anatomy  of,  241 

prognosis  of,  242 

treatment  of,  243 
Adult  spinal  paralysis,  287 
^jEsthesiometer,  the,  25 

Sieveking's,  26 
Affections  of  the  organs  of  speech  in  cho- 
rea, 484 
Agraphia,  183 
Albuminuric  aphasia,  198 
Alcohol  in  urine,  means  of  detecting,  437 

in  ventricular  fluid,  435 
Alcoholism,  430 

acute,  430 


Alcoholism  (continued) 
causes  of,  434 
chronic,  432 
definition  of,  430 
diagnosis  of,  437 
hallucinations  in,  431 
morbid  anatomy  and  pathology  of, 

435 
prognosis  of,  437 
symptoms  of,  430 
treatment  of,  438 
Amblyopia  as  a  symptom  of  brain  tumor, 

209 
Amidon  on  tetanus,  378 
Aneemia,  cerebral,  127 

spinal,  259 
Anesthesia,  542 
causes  of,  542 

diagnosis  and  prognosis  of,  544 
of  fifth  nerve,  543 
hysterical,  457 
of  radial  nerve,  449 
symptoms  of,  542 
treatment  of,  544 
Angular  gyrus,  functions  of,  194 
Aneurism  of  cerebellum,  229 

miliary,  113 
Antero-lateral  amyotrophic  sclerosis,  342 
causes  of,  345 
diagnosis  of,  346 
morbid  anatomy  of,  345 
prognosis  of,  346 
symptoms  of,  342 
synonyms  of,  342 
treatment  of,  346 
Antero-spinal  paralysis  of  adults,  287 
causes  of,  291 
definition  of,  287 
diagnosis  of,  292 
morbid   anatomy   and    pa- 
thology of,  292 
prognosis  of,  292 
symptoms  of,  287 
synonyms  of,  287 
treatment  of,  294 
of  infants,  277 

589 


590 


INDEX. 


Antero-spinal  paralysis  (continued) 
causes  of,  281 
definition  of,  277 
deformities  in,  279 
diagnosis  of,  285 
electricity  in,  285 
morbid   anatomy   and    pa- 
thology of,  282 
muscular  tissue,  changes  in, 

284 
prognosis  of,  285 
Sinkler'e  cases  of,  278 
symptoms  of,  278 
synonyms  of,  277 
treatment  of,  285 
Aphasia,  179 

children,  of,  194 
definition  of,  179 
diagnosis  of,  195 
history  of,  180 
infantile,  194 

location  of  speech  centre  in,  186 
Lordat  on,  182 
medico-legal  study  of,  197 
of  Dr.  Allin,  193 
synonyms  of,  179 
treatment  of,  199 
with  left  sided  paralysis,  189 
Apoplexy,  90 
Apparatus,  electrical,  34 

for  the  treatment  of  nervous  diseases, 
34 
Arthropathies  in  locomotor  ataxia,  325 
Ascending  degeneration  of  posterior  col- 
umns, 341 
Asemasia,  179 
Asphyxie  locale,  544 
Atheromatous  changes  in  vessels,  113 
Athetosis,  99 

Atrophy,  partial  facial,  308 
causes  of,  310 
diagnosis  of,  310 
Draper's  case  of,  308 
pathology  of,  310 
prognosis  of,  310 
synonyms  of,  308 
symptoms  of,  308 
treatment  of,  311 
of  cerebellum,  225 
progressive  muscular,  295 
Auditory  vertigo,  139 
causes  of,  141 
definition  of,  139 
diagnosis  of,  143 
pathology  of,  141 


Auditory  vertigo  (continued) 

synonyms  of,  139 

treatment  of,  143 
Auditory  epilepsy,  400 
Automatic  man,  the,  390 

BASEDOW'S  disease,  503 
Basilar  meningitis,  58 
Bed-sores,  268 
Bell's  paralysis,  549 
Benzine  cautery,  the,  37 
Bilateral  facial  paralysis,  549 
Blanching  of  fingers,  544 
Bloodletting  in  apoplexy,  123 
Blue  line,  the,  566 
Bone  changes  in  posterior  spinal  sclerosis, 

325 
Brain,  inflammation  of,  164 

red  softening  of,  170 

syphilitic  disease  of,  173 
tumors,  205 

choked  disk  a  symptom  of,  208 

diagnosis  of,  219 

localization  of,  220 

morbid  anatomy  of,  211 

prognosis,  222 

symptoms  of,  205 

treatment  of,  223 
Brittle ness  of  bones  in  locomotor  ataxia, 

326 
Bromides  in  epilepsy,  405 
Bulbar  diseases,  384 
paralysis,  414 

causes  of,  418 

diagnosis  of,  420 

morbid  anatomy  and  pathology 
of,  418 

prognosis  of,  420 

progressive  variety  of,  417 

reflex  variety  of,  417 

stationary  variety  of,  417 

symptoms  of,  415 

synonyms  of,  414 

treatment  of,  420 

CANCEROUS  growths  in  brain,  212 
Case  of  cerebellar  tremor,  227 
of  Dr.  Allin,  193 
of  post-paralytic  chorea,  98 
Catalepsy,  479 
causes  of,  480 
definition  of,  479 
diagnosis  of,  482 
flexibilitas  cerea  in,  480 
induced  in  animals,  482 


INDEX. 


591 


Catalepsy  (continued) 
malarial,  480 
morbid  anatomy  and   pathology  of, 

481 
prognosis  of,  482 
symptoms  of,  479 
treatment  of,  482 
Catlin's  observations,  527 
Cauteries,  36 
author's,  36 
glass  rod,  36 
Guerard's,  37 
Pacquelin's,  37 
Central  neuritis,  208 

spinal  hemorrhage,  251 
Centre,  auditory,  194 
Cerebral  anjemia,  symptomatic,  127 
causes  of,  130 
chronic,  128 
definition  of,  127 
infantile,  129 
morbid  anatomy  and  pathology 

of,  132  . 
prognosis  of,  135 
symptoms  of,  128 
synonyms  of,  127 
treatment  of,  135 
congestion,  76 
hemorrhage,  90 

attacks  of,  without  loss  of  con- 
sciousness, 94 
causes  of,  101 
condition  of  eyes  in,  93 
conjugate  deviation  of  eyes  in,  93 
definition  of,  90 
diagnosis  of,  115 
morbid  anatomy  and  pathology 

of,  104 
post-paralytic  states  in,  98 
prodromata  of,  90 
prognosis  of,  119 
psychical  disturbance  in,  92 
residual  paralysis  in,  95 
respiratory  disturbance  in,  93 
seat  of,  115 
symptoms  of,  90 
tendon  reflex  in,  100 
time  of  attack  of,  103 
treatment  of,  122 
hypersemia,  symptomatic,  76 
causes  of,  77 
definition  of,  76 
diagnosis  of,  86 
morbid  anatomy  of,  85 
pathology  of,  83 


Cerebral  hyperaemia,  symptomatic,  {con- 
tinued). 
prognosis  of,  88 
symptoms  of,  77 
synonyms  of,  77 
treatment  of,  88 
meninges,  diseases  of,  38 
meningitis,  acute,  48 
causes  of,  49 
diagnosis  of,  50 
pathology  and  morbid  ana- 
tomy of,  50 
prognosis  of,  54 
symptoms  of,  48 
treatment  of,  54 
chronic,  71 

treatment  of,  75 
pachymeningitis,  38 

acute,  symptoms  of,  40 
chronic,  causes  of,  43 

morbid  anatomy  and  patho- 
logy of,  43 
osseous  plates  in,  43 
prognosis  of,  44 
symptoms  of,  40 
treatment  of,  44 
with  hsematoma,  44 
case  of,  46 
causes  of,  45 
formation  of  cysts  in,  45 
morbid   anatomy   and    pa- 
thology of,  45 
prognosis,  of,  48 
symptoms  of,  44 
treatment  of,  48 
rheumatism,  55 
sclerosis,  199 

causes  of,  203 
definition  of,  199 
difi'used,  199 
diagnosis  of,  204 
prognosis  of,  204 
symptoms  of,  200 
synonyms  of,  199 
treatment  of,  204 
softening,  164 
acute,  165 

causes  of,  167 
diagnosis  of,  168 
morbid    anatomy   and    pa- 
thology of,  167 
prognosis  of,  169 
symptoms  of,  165 
treatment  of,  169 
chronic,  170 


592 


INDEX. 


Cerebral  softening,  chronic,  {continued) 
causes  of,  173 
definition  of,  170 
diagnosis  of,  177 
morbid   anatomy   and    pa- 
thology of,  174 
prognosis  of,  178 
8}'raptoms  of,  170 
treatment  of,  179 
classification  of,  161 
definition  of,  164 
thermometry,  23 

tumors,  Gragset's  classification  of,  211 
localization  of,  220 
Cerebellum,  tumors  of,  225 
softening  of,  229 
abscess  of,  229 
atrophy  of,  225 
tumors  of,  226 
hemorrhage  of,  225 
Cerebellar  disease,  223 

diagnosis  of,  234 
prognosis  of,  234 
treatment  of,  235 
Cerebritis,  165 
Cerebro-spinal  diseases,  421 
meningitis,  421 

retraction  of  head  in,  422 
Cerebrum  and  cerebellum,  diseases  of,  76 
Cervical  pachymeningitis,  238 
Cervico-brachial  neuralgia,  519 
Cervico-occipital  neuralgia,  518 
Character    of   the    deposit    in    so-called 

tubercular  meningitis,  66 
Charcot  on  reduced  temperature  in  hys- 

tero-epilepsy,  479 
Chloral-bromide   treatment    in   epilepsy, 

408 
Choked  disk,  208      . 
Chorea,  483 
adult,  488 

among  school  children,  491 
causes  of,  490 
definition  of,  483 
dependent  upon  tapeworm,  486 
diagnosis  of,  495 
embolic  theory  of,  491 
epidemic,  483 

ether  spray  in  treatment  of,  496 
heart  lesions  of,  492 
irregular  forms  of,  486 
hyoscyamia  in,  497 
malarial,  491 

m6rbid   anatomy  and  pathologv  of, 
491 


Chorea  (continued) 

of  pregnancy,  488 
post-paralytic,  98 
prognosis  of,  496 
rare  among  negroes,  490 
symptoms  of,  484 
synonyms  of,  483 
treatment,  496 
with  eczema,  490 
Chronic   cerebral   pachymeningitis    with 
haematoma,  44 
myelitis,  269 
Circulation  of  brain,  Duret  on,  111 

alcoholism,  432 
Clavus  hystericus,  455 
Color  blindness,  441 
Columns  of  Gall,  sclerosis  of,  341 
Condition  of  organs  of  generation  in  hys- 
teria, 455 
Congestion,  cerebral,  76 

spinal,  255 
Congestive  pernicious    fever,   its   resem- 
blance to  cerebro-spinal  meningitis,  424 
Constriction  band,  the,  269 
Contractions,  fibrillary,  296 

of  muscles  in  cerebro-spinal  menin- 
gitis, 422 
Contractures   in   antero-lateral   sclerosis, 
342 
in  hemiplegia,  98 
in  infantile  paralysis,  279 
in  hysteria,  459 
Contusions    and    punctured   wounds    as 

causes  of  paralysis,  555 
Convulsion  as  symptom  of  brain  tumor, 

205 
Corpuscles,  Gluge's,  175 
Cramp,  dancer's,  582 
telegrapher's,  582 
writer's,  582 
professional,  582 
causes  of,  584 
diagnosis  of,  585 
pathology  of,  584 
"  Crises  gastriques,"  328 
Cross  paralysis,  115 
Crum-Brown's  experiments,  140 
Cutaneous  eruptions  iii  locomotor  ataxia 

325 
Cutaneous  eruptions  in  neuritis,  539 

DA  COSTA  on  cerebral  rheumatism,  50 
Decubitus  paralysis,  557 
Decussation  of  optic  fibres,  209 
Delirium  tremens,  430 


INDEX.- 


593 


Depraved  appetite  m  hysteria,  456 
Diathetic  growths,  212 
Diphtheritic  paralysis,  562 
Diseases  of  cerebral  meninges,  38 

of  cerebrum  and  cerebellum,  76 

of  lateral  columns,  Si? 
Dislocation  as  a  cause  of  paralysis,  555 
Disseminated  sclerosis,  424 
Division  of  a  nerve  trunk  as  a  cause  of 

paralysis,  560 
Dorsal-clonus,  350 
Douleureux,  tic,  513 
Dynamometer,  28 

Mathieu's,  29 

the  author's,  30 

ECHOLALIA,  196 
Eczema  with  chorea,  490 
Education  of  right  side  of  brain,  199 
Electrical  apparatus,  34 
Embolism,  154 

of  the  cerebral  vessels,  154 
causes  of,  157 
diagnosis  of,  158 
morbid    anatomy   and   pa- 
thology of,  161 
prognosis  of,  163 
symptoms  of,  154 
treatment  of,  163 
Endemic  tetanus,  374 
Endoarteritis,  syphilitic,  177 
Epidemic  chorea,  483 
Epilepsy,  384 
aborted,  390 
.  abuse  of  bromides  in,  406 
age  in  causation  of,  393 
auditory,  400 

Brown-Sequard's  experiments  in,  398 
causes  of,  393 

condition  of  pupils  in,  392-403 
definition  of,  384 
diagnosis  of,  402 
dislocation  of  bones  in,  388 
experimental  production  of,  398 
grave  attacks  of,  385 
heredity  in,  394 
history  of,  384 
hystero,  470 

induration  of  cornua  ammonis,  396 
irregular  attacks  of,  390 
Jackson  on,, 399 
light  attacks  of,  389 
"  masked,  390 
morbid  anatomy  and   pathology  of, 
396 

38 


Epilepsy  (continued) 
nocturnal,  388 
prognosis  of,  403 
responsibility  in,  392 
symptoms  of,  385 
synonyms  of,  384 
syphilitic,  403 

temperature  influences  in,  394 
tongue  biting  in,  387 
treatment  of,  404 
warnings  in,  385 
Epileptiform  tic,  513 

hj^steria,  470 
Equilibrium,  sense  of,  the,  334 
Erotogenetic  zones,  479 

with  locomotor  ataxra-  325 
Essential  paralysis,  287 
Etat  crible,  the,  85 
Examination  of  pupils,  33 

post-mortem,  18 
Exhaustion   simulating  acute   tubercular 

meningitis,  70 
Exophthalmic  goitre,  503 
causes  of,  508 
definition  of,  503 
diagnosis  of,  509 
morbid  anatomy  and  pathologv 

of,  508 
prognosis  of,  509 
symptoms  of,  503 
synonyms  of,  503 
treatment  of,  509 
skin  changes  in,  506 

FACIAL  neuralgia,  513   ^  : ' 

paralysis,  549  • 

causes  of,  550 
diagnosis  of,  552 
electricity  in,  553 
pathology  of,  551 
prognosis  of,  553 
symptoms  of,  549  , 
synonyms  of,  540  c 

'treatment  of,  553 
wire  hook  in  treatment  of,  553 
spasm  without  pain,  556 
Faradic  apparatus,  34 
Fibrillary  contractions,  296 
Flechsig's  investigations,  361 
Flexibilitas  cerea,  480 
Function  of  angular  gyrus,  194 
Functional  disease  of  lateral  columns,  354 

&ALVANIO  batteries,  34 
General  paresis,  false,  173 


694 


INDEX. 


Gibney  on  traumatic  causation  of  spinal 

irritation,  259 
Glass  rod  cautery,  36 
Gliomata  of  brain,  213 
Globus  hystericus,  the,  462 
Gluge's  corpuscles,  175 
Goitre,  exophthalmic,  503 
Grasset's  classifica  ion  of  brain  tumors,  211 
Graves'  disease,  503 
GrifBn  on  spinal  irritation,  259 

HARDENING  fluids,  20 
Hemiplegia,  95 

hysterical,  458 
Hemorrhage,  cerebral,  flO 
.meningeal,  115 
spinal,  251 
,  .cerebellar,  225 
Hejedity.  in  pseudo-hypertrophic  paraly- 
sis, 3}7 
High  tempe^atjure  in  tetanus,  372 
Hints  in  regard  to  methods  of  examina- 
tion and  study,  17 
Holland  on  leeching,  54 
Hydrobromic  acid,  89 
Hydroiodic  acid  in  gotit.re,  510 
Hydromyelia,  360 
Hydrophobia,  444 
causes  of,  450 
curare  in,  454 
diagnosis  of,  453 
Dr.  Hadden's  case  of,  445 
morbid  anatomy  and   pathology  of, 

450 
prognosis  of,  454 
symptoms  of,  444 
eynoayms  of,  444 
treatment  of,  454 
Hysteria,  454 
causes  of,  463 
definition  of,  454 
diagnosis  of,  467 
in  children,  463 
morbid   anatomy  and  pathology  of, 

466 
:  prognosis  of,  468 
symptoms  of,  455 
treatment  of,  468 
Hysterical  .ajisegtheBia,  45.7 
.ataxia,  337 
contracture,  459 
eye  troubles,  458 
hemiplegia,  460 
paraplegia,  458 
spasmodic  spinal  paralysis,  355 


Hystero-epilepsy,  470 
symptoms  of,  471 
treatment,  479 

INFANTILE  hemiplegia,  277 
hysteria,  463 
paralysis,  277 
spasmodic  paralysis,  353 
Inflammation  of  spinal  cord,  265 
Instruments   used   for   the    diagnosis   of 

nervous  diseases,  22 
Intra-cranial  vessels,  embolism  of,  145 
Intra-vesical  troubles  in  myelitis,  265 
Irritation,  spinal,  259 
cause  of,  261 
diagnosis  of,  263 
morbid  anatomy  and  ipathology  of, 

262 
prognosis  and  treatment  of,  265 

TACKSON  on  epilepsy,  399 

LATERAL  columns,  hysterical  disease 
of,  355 
Lateral  sclerosis  of  the  spinal  cord,  347 
■  diagnosis  of,  368 

'.  morbid  anatomy  of,  360 

prognosis  of,  368 
symptoms  of,  347 
synonyms  of,  347 
treatment  of,  369 
.Lead  poisoning,  566 
causes  of,  568 
diagnosis  of,  572 
morbid  aaatomy  and  pathology 

of,  571 
prognosis  of,  572 
synonyms  of,  -566 
treatment  of,  572 
Lesions  in  epilepsy,  397 
Local  paralysis,  548 
Localization  of  tumors,  220 

of  cerebellar  disease,  233 
of  cerebral  hemorrhage,  104 
Locomotor  ataxia,  321 
hysterical,  337 


nyrAIN  en  griffe,  296 


Male  hysteria,  462 
Mastodynia,  523 
Meniere's  disease,  139 
Meningeal  hemorrhage,  115 
Meningitis,  acute  and  chronic  spinal,  236 
symptoms  of,  236 
granular,  58 


INDEX, 


595 


Meningitis  {continued} 
cerebro-spinal,  421 
causes  of,  423 
definition  of,  42t 
diagnosis  of,  423 
morbid  anatomy  and  pathology 

of,  423 
prognosis  of,  424 
symptoms  of,  421 
synonyms  of,  421 
treatment  of,  424 
chronic  cerebral,  71 
causes  of,  74 
diagnosis  of,  74 
morbid    anatomy    and    pa- 
thology of,  74 
prognosis  of,  75 
symptoms  of,  71 
treatment  of,  75 
of  the  aged,  57 
rheumatic,  55 
senile,  57 

tubercular  (granular),  58 
basal,  58 
causes  of,  63 
development  of,  63 
diagnosis  of,  68 
morbid  anatomy  and  pathology 

of,  65 
prognosis  of,  68 
symptoms  of,  58 
treatment  of,  70 
tubercular  deposits  in,  65 
vertical,  63 
Meningo-cerebritis,  165 
Mental  changes  in  locomotor  ataxia,  327 
Migraine,  513 
Miliary  aneurisms,  113 
Mimetic  chorea,  483 
Morbid  impulses  in  hysteria,  456 
Mortality  in  tubercular  meningitis,  64 
Mottled  skin  in  pseudo-hypertrophic  pa- 
ralysis, 312 
Multiple  embolism,  161 
Muscular  rheumatism,  541 
Myelitis,  265 

causes  of,  270 
chronic,  269 
diagnosis  of,  272 
■  morbid    anatomy  and  pathology  of, 
271 
prognosis  of,  274 
symptoms  of,  269 
treatment  of,  274 
vesical  troubles  in,  268 


NEEVES,  tumors  of,  547 
Nerve-stretching,  534,  541 
Neuralgia,  age  and  sex  in  causation  of 
524 

association  with  epilepsy,  524 

bad  teeth  as  a  cause  of,  526 

causes  of,  524 

cervico-occipital,  518 
brachial,  519 

circulatory  disturbances  in,  512 

clavus,  515 

coarse  and  fine  varieties  of,  531 

crural,  522 

definition  of,  511 

diagnosis  of,  528 

electricity  in  treatment  of,  584 

excision  of  supra-orbital  in,  516 

facial,  513 

influence  of  temperature  in,  527 

intercostal,  520 

inveterate,  an,  case  of,  529 

morbid  anatomy  of,  528 

nerve  areas  in,  532 

nerve  section  in,  516 

of  testis,  523 

ovarian,  523 

prognosis  of,  529 

renal,  523 

sciatic,  520 

syphilitic,  525 

treatment  of,  531 

trigeminal,  513       , 

trophic  disturbances  in,  512 

urethral,  523 

Granville's  apparatus  in,  528 

visceral,  522 
Neuritis,  538 

causes  of,  540 

morbid  anatomy  and    pathology  of, 
540 

nerve  section  in,  541 
stretching  in,  541 

prognosis  of,  541 

symptoms  of,  538 

treatment  of,  541 

trophic  changes  in,  538 
Neuromata,  sarcomatous,  547 

treatment  of,  547 
Nicotinism,  439 

causes  of,  442 

prognosis  and  treatment  of,  443  • 

symptoms  of,  440 
Nystagmus,  189 


596 


I K  D  E  X  . 


OCCLUSION  of  intracranial  vessels,  145 
Occupation,  and  its  relation  to  cere- 
bral hyperjEmia,  81 
Ocular  trouble  witb  brain  tumor,  208 

in  locomotor  ataxia,  323 
CEsophagisraus,  587 
Ophthalmoscope,  the,  30 
Opisthotonos,  371 

Organs  of  speech,  affection  of  in  chorea, 
484 


PACHYMENI'nGITIS   as   a  result  of 
injury,  38 
cerebral,  33 
spinal,  causes  of,  238 

diagnosis  of,  243 

morbid  anatomy  and  pathology 
of,  241 

prognosis  of,  242  , 

s3'mptoms  of,  236 

treatment  of,  243. 
with  hsematoma,  44 
Painters'  colic,  566 
Palsy,  Scrivener's,  582 
shaking,  498 
wasting,  295 
Paralysis,  adult  spinal,  287 
acute  ascending,  275 
after  dislocation,  555 
agitans,  498 

case  of,  499 

causes  of,  500 

diagnosis  of,  501 

morbid  anatomy  and  pathology 
of,  500 

prognosis  of,  502 

symptoms  of,  49.S 

synonyms  of,  498 

treatment  of,  502. 
antero-spinal,  of  infancj",  277 
bulbar,  414 
cross,  115 
Cruveilhier's,  295 
diphtheritic,  562 

causes  of,  564 

diagnosis  of,  565 

morbid  anatomy  and  pathology 
of,  564 

prognosis  of,  565 

sj^mptoms  of,  562 

treatment  of,  565 
facial,  549 

from  pressure  of  forceps,  556 
heat  in  the  treatment  of,  126 


Paralysis  [continued) 
hysterical,  160 
local,  548 
of  sphincters,  268 
pseudo-hypertrophic,  311 
residual,  95 
temporary  spinal,  291 
traumatic,  555 
Paralytic  chorea,  485 
Paraplegia,  267 

hysterical,  460 
Paresis,  general,  173 
Parkinson's  disease,  498 
Partial  celebral  ansmia,  145 
Partial  facial  atrophy,  308 
Passive  cerebral  hyperasmia,  77 
Percussion  hammer,  33 
Percuteur,  the,  535 
Perivascular  spaces,  the,  86 
Petrina  on  localization,  220 
Pleurodynia,  520 
Pleurosthotonos,  371 
Poisoning,  lead,  566 
Posterior  spinal  sclerosis,  321 

ascending  and  descending, 

322 
causes  of,  329 
diagnosis  of,  336 
morbid  anatomy  and  patho- 
logy of,  330 
neuralgia  in,  321 
periods  of  improvement  in, 

339 
prognosis  of,  338 
state  of  mind  in,  327 
symptoms  of,  321 
synonyms  of,  321 
treatment  of,  339 
Posthemiplegic  disorders  of  movement,  98 
Post-paralytic  chorea,  98 
Primary  and  compensatory  contractions 

in  paralysis,  279 
Primary  degeneration  of  lateral  columns, 

356 
Prodromata  of  infantile  palsy,  277 
Professional  ciamp,  582 

muscular  atrophy,  486 
Prognosis  in  syphilitic  brain  disease,  179 
Progressive  muscular  atrophy,  295 
causes  of,  299 
definition  of,  295 
diagnosis  of,  304 
history  of,  295 
morbid  anatomy  and  patho- 
logy of,  301 


INDEX. 


597 


Progressive  muscular  atrophy  {continued) 

prognosis  of.  307 
'       •        resembling  lead  palsy,  304 

skin  changes  in,  299 

symptoms  of,  295 

synoDj-ms  of,  295 

treatment  of,  307 
Progressive  Paresis  and  locomotor  ataxia, 

326 
Pseudo-hypertrophic  muscular  paralysis, 

311 

cases  of,  271 

causes  of,  317 

diagnosis  of,  319 

heredity  in,  317 

lordosis  in,  315 

pathology  and  morbid  ana- 
tomy of,  318 

prognosis  of,  320 

symptoms  of,  311 

synonyms  of,  311 

treatment  of,  320 
Puerperal  embolism,  158 
hysteria,  464 

"p  ABIES  canina,  444 

JAi     Red  softening,  170 

Pk,eflex  spasm,  577 

P.,etraction  of  head  in  cerebro-spinal  me- 
ningitis, 422 

Rheumatic  meningitis,  55 

Risus  sardonicus,  370 

Romberg  on  delayed  transmission  of  pain- 
ful impressions,  269 

Rubber  muscle,  the,  35 

SCIATICA,  520 
Sclerosis,  antero-lateral,  342 
cerebral,  199 
diffused,  200 
of  columns  of  Goll,  S41 
cerebro-spinal,  424 
causes  of,  425' 
diagnosis  of,  429 
morbid  anatomy  and  pathology 

of,  429 
prognosis  of,  429 
symptoms  of,  425 
synonyms  of,  424 
treatment  of,  429 
disseminated,  424 
lateral,  317 

deformity  of  feet  in,  357 
posterior-spinal,  321 
Sclerose  en  plaques,  424 


Scrivener's  palsy,  582 
Seat  of  cerebral  hemorrhage,  115 
Secondarj'    degeneration    of   lateral    col- 
umns, 99 
Senile  meningitis,  57 
Seventh  nerve,  paralysis  of,  549 
Shaking  palsy,  498 
Sieveking's  sesthesiometer,  22 
Sleep  not  necessarily  due  to  cerebral  anae- 
mia, 134 
Softening  after  vascular  plugging,  145 
cerebral,  164 
cerebellar,  229 

not  necessarily  an  inflammatory  pro- 
cess, 164 
of  posterior  columns  in  tetanus,  378 
Spaces,  the  perivascular,  86 
Spasm,  facial,  without  pain,  576 
from  genital  irritation,  577 
functional,  576 

with  voluntary  movements,  576 
pathology  of,  579 
reflex,  577 
treatment  of,    579 
Spasmodic  spinal  paralysis,  356 
Spinal  anaemia,  so  called,  259 

Gibney  on  traumatic  causation 

of  259 
Griffin  on,  259 
congestion,  255 

symptoms  of,  259 
hemorrhage,  251 
causes  of,  252 
diagnosis  of,  254 
morbid  anatomy  and  pathology 

of,  253 
prognosis  of,  254 
symptoms  of,  251 
synonyms,  251 
treatment  of,  254 
hyperemia,  subacute,  256 
causes  of,  256 
diagnosis  of,  257 
morbid  anatomy  and  patho- 
logy of,  257 
prognosis  of,  258 
symptoms  of,  256 
treatment  of,  258 
irritation,  259 
causes  of,  261 
diagnosis  of,  263 
morbid  anatomy  and  pathology 

of,  262 
prognosis  of,  263 
symptoms  of,  259 


598 


INDEX. 


Spinal  irritation  (continued) 
treatment  of,  263 
meninges,  diseases  of,  236 
meningitis,  acute  and  chronic,  236 
pachymeningitis,  238 
causes  of,  240 
symptoms  of,  238 
paralysis,  temporary,  251 
tumor,  245 

causes  of,  250 

diagnosis  of,  250 

morbid  anatomy  and  pathology 

of,  250 
prognosis  of,  250 
symptoms  o-f,  245 
treatment  of,  251 
varieties  of,  245 
Spotted  fever,  421 
Staining  solutions,  21 
Sthenic  cerebral  hyperjemia,  77 
Stomachic  vertigo,  138 
St.  Vitias'  dance,  483 
Sulphur  baths  in,  locomotor  ataxia,  340 
Syncope,  127 

Syphilis  of  the  brain,  173,  179 
Syphilitic  encepbalopathie,  177 
"         epileps}'',  403 
"         myelitis,  270 
"         neuralgia,  5.25 
"         pachymeningitis,  41 

TABES  dorsalis,  321 
Tache  cerebrale,  61 
Tarantism,  484 

Temporary  spinal  paralysis,.  291 
Tendon-reflex,  absent,  322 

in  lateral  sclerosis,  358 
method  of  testing,  34 
Tetanoid  paraplegia,  356 
Tetanus,  370 

allied  to  strychnia  poisoning,  379 

causes  of,  373 

curare  in,  382 

chloral  h3'drate  in,  .382 

definition  of,  370 

diagnosis  of,  380 

endemic,  374 

morbid  anatomy  and  pathology  of, 
377 

nascentium,  373 

on  Long  Island,  374 

pleurosthotonos  in,  371 

prognosis  of,  381 

risus  sardonicus  in,  370 

softening  of  posterior  columns  in,  378 

statistics  of,  374 

symptoms  of,  370 


Tetanus  (continued) 
synonyms  of,  370 

rise  of  temperature  in,'  372 
treatment  of,  381 
urine  in,  372 
Tetany,  576 
The  epileptic  zone,  398 
Theory  of  sleep,  134 
Thermometer,  the,  22 
Thermometry,  cerebral,  23 
Thrombosis,  145 

of  cerebral  arteries,  146 
causes  of,  149 
diagnosis  of,  151 
morbid  anatomy  and  patho- 
logy of,  149 
treatment  of,  151 
of  sinuses  and  veins,  151 

after  aural  disease,  153 
Tic  douleureaux,  513 
Tobacco  amblyopia,  441 
Tonga,  536 
Torticollis,  578 
Transposition  in  aphasia,  183 
Traumatic  paralysis,  555 
diagnosis  of,  559 
prognosis  of,  559 
treatment  of,  560 
Treatment  of  bed-sores,  274 
Tremor,  17 

functional,  576 
Tri-nitro  glycerine,  413 
Trismus  nascentium,  373 
Trophic  changes  in  traumatic  paralysis, 

560 
Tumors  of  brain,  205 
of  cerebellum,  226 
of  nerves,  546 
spinal,  245 

UNILATERAL  tremor  as  a  result  of 
localized  meningitis,  50 
Urine  in  tetanus,  372 

VARIATIONS  of  temperature  in  cere- 
bral hemorrhage,  94 
Vertigo,  139 

"         stomachic,  138 
Visual  word  centre,  194 

WIRE   hook   in  treatment  of  facial 
paralysis,  553 
Writer's  cramp,  582 
Wasting  palsy,  295 

ZONE,  the  epileptic,  398 
hysterogenetic,  478 


HENRY  C.  LEA'S  SON  &  CO.'S 

(LATE  HEI^RT  C.  LEA) 

OF 

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the  confidence  earned  for  the  publications  of  the  house  by  their  careful  selection  and 
accuracy  and  finish  of  execution. 

The  large  numher  of  inquiries  received  from  the  prof ession  for  a  finer  class  of  bind- 
ings than  is  usually  placed  on  medical  books  has  induced  us  to  put  certain  of  our 

andard  publications  in  half  Russia,  and  that  the  groiving  taste  may  be  encouraged, 
the  prices  have  been  fixed  at  so  small  an  advance  over  the  cost  of  sheep,  as  to  place  it 
toithin  the  means  of  all  to  possess  a  library  that  shall  have  attractions  as  well  for  the 
eye  as  for  the  mind  of  the  reading  practitioner. 

The  printed  prices  are  those  at  which  books  can  generally  be  supplied  by  book- 
sellers throughout  the  United  States,  who  can  readily  procure  for  their  customers  any 
works  not  kept  in  stock.  Where  access  to  bookstores  is  not  convenient,  books  will  be 
sent  by  mail  post-paid  on  receipt  of  the  price,  and  as  the  limit  of  mailable  weiglit  has 
been  removed,  no  difficulty  will  be  experienced  in  obtaining  through  the  post-office 
any  work  in  this  catalogue.  No  risks,  however,  are  assumed  either  on  the  money  or 
on  the  books,  and  no  publications  but  our  own  are  supplied,  so  that  gentlemen  will  in 
most  cases  find  it  more  convenient  to  deal  with  the  nearest  bookseller. 

HENRY  C.  LEA'S  SON  &  CO. 

Nos.  706  and  708  Saxsom  St.,  Philadelphia,  November,  ISSl. 


INCREASED  INDUCEMENT  FOR  SUBSCRIBERS  TO 

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TWO  MEDICAL  JOURNALS,  containing  nearly  2000  LAEGE  PAGES, 

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The  periodicals  thus  offered  at  this  unprecedented  rate  are  universally  known  for 


2     Henkt  C.  Lea's  Son  &  Co.'s  Publications — (Am.  Journ.  Med.  Set.). 
their  high  professional  standing. 

THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES, 

Edited  by  I.  MINIS  HAYS,  M.D., 
for  more  than  half  a  century  has  maintained  its  position  in  the  front  rank  of  the 
medical  literature  of  the  world.  Cordially  supported  by  the  profession  of  America,  it 
circulates  -wherever  the  language  is  read,  and  is  universally  regarded  as  the  national 
exponent  of  American  medicine — a  position  to  which  it  is  entitled  by  the  distinguished 
names  from  every  section  of  the  Union  wliich  are  to  be  found  among  its  collaborators.* 
It  is  issued  quarterly,  in  January,  April,  July,  and  October,  each  number  containing 
about  three  hundred  octavo  pages,  appropriately  illustrated  wherever  necessary.  A 
lar"e  portion  of  this  space  is  devoted  to  Original  Communications,  embracing  papers 
from  the  most  eminent  members  of  the  profession  throughout  the  country. 

Following  this  is  the  Revikw  Depaktment,  containing  extended  reviews  by  com- 
petent writers  of  prominent  new  works  and  topics  ol  the  day,  together  with  numerous 
slaborate  Analytical  and  Bibliographical  Notices,  giving  a  fairly  complete  survey  of 
iiedical  literature. 

Then  follows  the  Quarterly  Summary  of  Improvements  akd  Discoveries 
IN  THE  Medical  Sciences,  classified  and  arranged  under  different  heads,  and  furn- 
ishing a  digest  of  medical  progress,  abroad  and  at  home. 

Thus  during  the  year  1880  the  "Journal"  contained  67  Original  Communications, 
mostly  elaborate  in  character,  170  Reviews  and  Bibliographical  Notices,  and  147  articles 
in  the  Quarterly  Summaries,  illustrated  with  47  wood  engravings. 

That  the  efforts  thus  made  to  maintain  the  high  reputation  of  the  "Journal"  are 

successful,  is  shown  by  the  position  accorded  to  it  in  both  America  and  Europe  as  tlie 

leading  organ  of  medical  progress: — 

This  is  universally  acknowledged  as  the  leading  |  The  Philadelphia  Medical  and  Physical  Journal 
Aiiieiicau  Journal,  and  has  been  conducted  by  Dr.  i  issued  its  first  niuiiber  in  1820,  and,  after  a  brilliant 
Hays  alone  uutil  1809,  when  his  son  was  associaied  career,:  was  succeeded  in  1S27  by  the  American 
■wiih  him.  We  quite  agiee -with  the  critic,  lliat  this  !  Journal -ol  the  Medical  Sciences,  a  periodical  of 
jiurual  is  second  to  none  iu  ihe  language,  and  cheer-  world- 'wide»reputation  ;  the  ablest  and  one  of  the 
fully  accord  to  it  the  first  place,  for  nowhere  shall  oldesfperiodicalsin  the  world — a  journal  which  has 
we  find  more  able  and  more  impartial  criticism,  and  ■  an  unsullied  record. —  Gross's  History  of  Amtrican 


nowhere  such  a  repertory  of  able  original  articles 
Indeed,  now  that  the  "British  and  Foreign  Medico- 
C'h;rurgical  Review"  has  terminated  its  career,  the 
Au.erican  Journal  stauds  without  a  rival. — London 
Mtd.  Times  and  Gazette,  Hov.  24,  1S77. 
The  best  medical  journal  on  the  continent. — Bos- 
i.toit  Med.  and  Surg.  Journal,  April,  1879. 

The  present  number  of  the  American  Journal  is 
.-tafi  exceedingly  good  one,  and  gives  every  promi.se 
.  of    maintaining   the  well-earned   reputation  of  the 


Med.  Literature.    1S76. 

The  best'medical'journaleverpublished  in  Europe 
or  America. —  Va.  Med.  Monthly,  May,  1879. 

It  is  universally  acknowledged  to  be  the  leading 
American  medical  journal,  and,  in  oui  opinion,  is 
second  to  none  in  the  language. — Boston  Med.  and 
Surg.  Jottrnal,  Oct.  1877. 

This  is  the  medical  journalof  our  country  to  which 
the  American  physician  abrond  will  point  with  the 
greatest  satisfaction,  as  rellectibg  tlie  state  of  medi- 


ra-.'iew.  Our  venerable  contemporary  has  our  best  '  l^^  culture  in  his  country  For  a  great  many  years 
•  wishes,  and  we  can  only  e.xpre.ss  the  hope  that  U  I  jj  j,^^  ^^^^^  jj^g  medium  through  which  our  ablest 

ii.iiy  continue  Us  work  with  as  much  vigor  and  ex- I  ,jy,.ijgjg  ^.^^^  ^^.^^^  known  their  discoveries  and 
,  ceU«ace  lor  the  next  filty  years  as  it  bas  exhibited  kbgervations.-^ddres.s  of  L.  P.  TnndM,  M.O.,  be- 
.  in  the  pi,st..— London  Lar.cet,  Nov.  24,  1877.  [y.„^g  j7Uernational  Med.  Congress,  Sept.  1S76. 

And  that  it  was  specifically  included  in  the  award  of  a  medal  of  merit  to  the  Pub- 
Clishers  in  the  Vienna  Exhibition  in  1873. 

The  subscription  price  of  the  "American  Journal  of  the  Medical  Sciences" 

has  never  been  raised  during  its  long  career.     It  is  still  Five  Dollars  per  annum  ; 

..and  when  paid  for  in  advance,  the  subscriber  receives   in  addition  the  "Medical 

Newsaj^d  Abstract,"  making  in  all  nearly  2000  large  octavo  pages  per  annum,  free 

.of  postage. 

11. 

THE  MEDICAL  NEWS  AND  ABSTRACT. 

Thirty-^ight  years  ago  the  "Medical  Nev^s"    was  commenced  as  a  monthly  to 
convey  to  the  subscribers  of  the  "American  Journal"  the  clinical  instruction  and 

*  Commnuic»tv*i.us  are  invited  from  gentlemen  in  all  parts  of  the  country.     Articles  inserted  by  the 
Editor  are  lib.fi!;>i.Ui;  paid  for  by  the  publishers. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Am.  Journ.  Med.  Sci.).    3 

current  information  which  could  not  be  accommodated  in  the  Quarterly.     It  consisted 

of  sixteen  pages  of  such  matter,  together  with  sixteen  more  known  as  the  Library 
Department  and  devoted  to  the  publishing  of  books.  With  the  increased  progress  of 
science,  however,  this  was  found  insufficient,  and  some  years  since  another  periodical, 
known  as  the  "Monthly  Abstract,"  was  started,  and  was  furnished  at  a  moderate 
price  to  subscribers  to  the  "American  Journal."  These  two  monthlies  have  been 
consolidated,  under  the  title  of  "The  Medical  News  and  Abstract,"  and  are 
furnished  free  of  charge  in  connection  with  the  "American  Journal." 

The  "News  AND  Abstract"  consists  of  64  pages  monthly,  in  a  neat  cover.  It 
contains  a  Clinical  Department  in  which  will  be  continued  the  series  of  Original 
American  Clinical  Lectures,  by  gentlemen  of  the  highest  reputation  through- 
out the  United  States,  together  with  a  choice  selection  of  foreign  Lectures  and 
Hospital  Notes  and  Gleanings.  Then  follows  the  Monthly  Abstract,  systemati- 
cally ari'anged  and  classified,  and  presenting  five  or  six  hundred  articles  yearly  ;  and 
each  number  concludes  with  an  Editorial  and  a  News  Department,  giving  cur- 
rent professional  intelligence,  domestic  and  foreign,  the  whole  fully  indexed  at  the  close 
of  each  volume,  rendering  it  of  permanent  value  for  reference. 

As  stated  above,  the  subscription  price  to  the  "News  and  Abstract"  is  Two 
Dollars  and  a  Half  per  annum,  invariably  in  advance,  at  which  rate  it  ranks  as  one 
of  the  cheapest  medical  periodicals  in  the  country.  But  it  is  also  furnished,  free  ot 
all  charge,  in  commutation  with  the  "American  Journal  of  the  Medical 
Sciences,"  to  all  who  remit  Five  Dollars  in  advance,  thus  giving  to  the  subscriber, 
for  that  very  moderate  sum,  a  complete  record  of  medical  progress  throughout  the 
world,  in  the  compass  of  about  two  thousand  large  octavo  pages. 

In  this  effort  to  furnish  so  large  an  amount  of  practical  information  at  a  price  so  un- 
precedentedly  low,  and  thus  place  it  within  the  reach  of  every  member  of  the  profes- 
sion, the  publishers  confidently  anticipate  the  friendly  aid  of  all  who  feel  an  interest  in 
the  dissemination  of  sound  medical  literature.  They  trust,  especially,  that  the  sub- 
scribers to  the  "American  Medical  Journal,"  wiU  call  the  attention  of  their 
acquaintances  to  the  advantages  thus  offered,  and  that  they  will  be  sustained  in  the 
endeavor  to  permanently  establish  medical  periodical  literature  on  a  footing  of  cheap- 
ness never  heretofore  attempted. 

PEEMIUM  rOK  OBTAINING  NEW  SUBSOEIBEES  TO  THE  "JOUENAL." 
Anv  gentleman  who  will  remit  the  amount  for  two  subscriptions  for  1881,  one  of 

which  at  least  must  be  for  a  new  subscriber,  will  receive  as  a  premium,  free  by  mail, 

a  copy  of  any  one  of  the  following  recent  works  : — 
"  Seiler  on  the  Throat"  (see  p.  19), 
"Barnes's  Manual  of  Midwifery"  (see  p.  24), 
"Browne  on  the  Use  of  the  Ophthalmoscope"  (see  p.  29), 
"Flint's  Essays  on  Conservative  Medicine"  (see  p.  15), 
"Sturges's  Clinical  Medicine"  (seep.  15), 
"Tanner's  Clinical  Manual"  (seep.  5), 
"West  on  Nervous  Disorders  of  Children"  (see  p.  21). 

%*  Gentlemen  desiring  to  avail  themselves  of  the  advantages  thus  offered  will  da; 
well  to  forward  their  subscriptions  at  an  early  day,  in  order  to  insure  the  receipt  of' 
complete  sets  for  the  year  1881. 

1^  The  safest  mode  of  remittance  is  by  bank  cheek  or  postal  money  order,,  drawn 
to  the  order  of  the  undersigned.  Where  these  are  not  accessible,  remlttances-for  the 
"Journal"  maybe  made  at  the  risk  of  the  publishers,  by  forwarding  in  registered 

Henry  C.  Lea's  Son  &  Co.,  Nos.  706  and  708  Sansom  St.,  Phila.,  Ea. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Dictionaries). 


nUNGLISON  {ROBLEF),  M.D., 

"^"^  Late  Professor  of  Institutes  of  Mi-Aicine  in  Jefferson  Medical  College,  Philadelphia. 

MEDICAL  LEXICON;   A  Dictionary  op  Medical  Science:  Con- 
taining a  concise  explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Pathology,  Hygiene,  Therapeutics.  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 
Jurisprudence  and  Dentistry.     Notices  of  Climate  and  of  Mineral  Waters  ;  Formulae  for 
Officinal,  Empirical  and  Dietetic  Preparations;  with  the  Accentuation  and  Etymology  of 
the  Terms,  and  the  French  and  other  Synonymes  ;  so  a.<  to  con.stitute  a  French  as-  well  as 
English  Medical  Lexicon.     A  New  Edition.     Thoroughly  Revi.«ed,  and  very  greatly  Mod- 
ified and  Augmented.     By  Richard  J.  1>cn6liso>'.  M.I).     In  one  very  large  and  hand- 
some royal  octavo  volume  of  over  1100  pages.    Cloth,  $6  50  ;  leather,  raised  bands,  $7  50  ; 
half  Russia,  $8.      {Lately  Issued.) 
The  object  of  the  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexicon  or 
dictionary  of  terms,  but  to  afford,  undereach,  a  condensed  view  of  its  various  medical  relations, 
and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.    Starting 
with  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
rev^isions,to  augment  its  completeness  and  usefulness,  until  at  length  it  has  attained  the  position' 
of  a  recognized  and  standard  authority  wherever  the  language  is  spoken. 

Special  pains  have  been  taken  in  the  preparation  of  the  present  edition  to  maintain  this  en- 
viable reputation  During  the  ten  years  which  have  elapsed  since  the  Inst  revision,  the  additions 
to  the  nomenclature  of  the  medical  sciences  have  been  greater  than  perhaps  in  any  similar  period 
of  the  past,  and  up  to  the  time  of  his  death  the  author  labored  a.ssiduously  to  incorporate  every- 
thing requiring  the  attention  of  the  student  or  practitioner.  Since  then,  the  editor  has  been 
equally  industrious,  so  that  the  additions  to  the  vocabulary  are  more  numerous  than  in  any  pre- 
vious revision.  Especial  attention  has  been  bestowed  on  the  accentuation,  which  will  be  found 
marked  on  every  word.  The  typigraphical  arrangement  has  been  much  improved,  rendering 
reference  much  more  easy,  and  every  care  has  been  taken  with  the  mechanical  execution.  The 
work  has  been  printed  on  new  type,  small  but  exceedingly  clear,  with  an  enlarged  page,  so  that 
the  additions  have  been  incorporated  with  an  increase  of  but  little  over  a  hundred  pages,  and 
the  volume  now  contains  the  matter  of  at  least  four  ordinary  octavos. 

A  bouk  well  known  to  our  reader.-*,  and  of  which  i  jiay  [;afely  confirm  the  hope  ventured  by  the  editor 
every  American  ought  to  be  proud.  When  the  learned  "that  the  work,  which  posses?e.<!  for  biin  a  filial  as  well 
author  of  the  work  pas.sed  away,  probably  all  of  us    *s  an  individual  interest,  will  be  found  worthy  a  eon- 


feared  lest  the  book  should  not  maintain  its  place 
in  the  advancing  science  whose  terms  it  defines.  For- 
tunately, Ur.  Kichard  J.  Dunglison,  having  assisted  his 
father  in  the  revision  of  several  editions  of  the  work, 
and  having  been,  therefore,  trained  in  the  methods  and 
imbued  witli  the  spirit  of  the  book,  has  been  able  to 
edit  it,  not  in  the  patchwork  manner  so  dear  to  the 
heart  of  book  editors,  so  repulsive  to  the  taste  of  intel- 
ligent book  readers, but  to  editit  as  a  work  of  the  kind 
should  be  edited — to  carry  it  on  steadily,  without  jar 
or  interruption,  along  the  grooves  of  thought  it  has 
travelled  during  its  lifetime.  To  show  the  magnitude 
of  the  task  which  Dr.  Dunglison  has  assumed  and  car- 
ried through,  it  is  only  necessary  to  stale  that  more 
than  six  thousand  new  subjects  have  been  added  in  the 
presentedition. — Phila.Med.  Times,  Jan.  3,  1874. 

About  the  first  hook  purcha.ied  by  the  medical  stu- 
dent is  the  Medical  Dictionary.  The  lexicon  explana- 
tory of  technical  terms  is  simply  usinequa  non.  In  a 
science  so  extensive,  and  with  such  collaterals  as  medi- 
cine, it  is  as  much  a  necessity  also  to  the  practising 
physician.  To  meet  the  wants  of  students  and  most 
physicians,  the  dictionary  must  be  condensed  while 
comprehensive,  and  practical  while  perspicacious.  It 
was  because  Dunglison's  met  these  indications  that  it 
became  at  once  the  dictionary  of  general  use  wherever 
medicine  was  studied  in  the  English  language.  In  no 
former  revision  have  the  alterations  and  additions  heeii 
80  great.  Morethan  six  thousand  new  subjects  and  terms 
have  been  added. The  chief  terms  havebeenset  in  black 
letter,  while  the  derivatives  follow  in  small  caps:  an 
arrangement  which  greatly  facilitates  reference.    We 


'inuance  of  the  position  so  long  accorded  to  it  as  a 
standard  authority." — Cincinnati  Clinic.  Jan.  10. 1874. 
It  ha»  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accaracyandexteni  of 
references. — London  Jlffdieo!  fJnze.tff  . 

As  a  standard  work  of  reference,  as  one  of  the  best, 
if  not  the  very  best,  medical  dictionary  in  the  Eng- 
lish language,  Dunglison's  work  has  been  well  known 
for  about  forty  years,  and  needs  no  words  of  praise 
on  our  part  to  recommend  it  to  the  members  ol  ihe 
medical,  and,  likewise,  of  the  pharmaceutical  pro- 
fession. The  latter  es|jecialiy  are  in  need  of  such  a 
work,  which  gives  ready  and  reliable  information 
on  thousands  of  subjects  and  terms  which  they  are 
liable  to  encounter  in  pursuing  their  daily  avoca- 
tions, but  with  which  they  cannot  be  expected  to  be 
familiar.  The  work  before  us  fully  supplies  this 
want. — Am.  Journ.  of  Pharm.,  Feb.  1874. 

A  valuable  dictionary  of  the  terms  employed  in 
medicine  and  the  allied  sciences,  and  of  the  rela- 
tions of  the  subjects  treated  under  each  head.  It  re- 
flects greai  credit  on  its  able  American  author,  and 
well  deserves  the  authority  and  popularity  it  has 
obtained. — British  Med.  Journ., Oct.  31,  1874. 

Few  works  of  this  class  exhibit  a  grander  monu- 
ment of  patient  research  and  of  scientific  lore.  The 
extent  of  the  sale  of  this  lexicon  is  sufficient  to  tes- 
tify to  it.-,  uteiulness,  and  to  the  greai  service  con- 
ferred by  Dr.  Robley  Dunglison  on  the  profession, 
and  indeed  on  others,  by  its  issue. — London  Lancet , 
May  13.  Is75. 


fJOBLYN  {RICHARD  D.),  M.D. 

A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND 

THE  COLLATERAL  SCIENCES.     Revised,  with  numerous  additions,  by  Isaac  Hays, 
M.D.,  Editor  of  the  "  American  Journal  of  the  Medical  Sciences."'     In  one  large  royal 
l2mo.  volume  of  over  600  double-columned  pages;  cloth,  $1  50  ;  leather,  $2  00 
It  is  the  best  boob  of  definitionu  we  have,  and  ought  always  to  be  upon  the  student's  table. — Southern 
Med.  and  Surg.  Journal. 

ODWELL  {G.  F.),  F.R.A.S.,  Src. 

A  DICTIONARY  OF  SCIENCE:  Comprising  Astronomy,  Chem- 
istry, Dynamics,  Electricity,  Heat,  Hydrodynamics,  Hydrostatics,  Light,  Magnetism, 
Mechanics,  Meteorology,  Pneumatics,  Sound  and  Statics.  Preceded  by  an  Essay  on  the 
History  of  the  Physical  Sciences.  In  one  handsome  octavo  volume  of  694  pages,  with 
many  illustrations  :  cloth,  $5. 


li 


Henry  C.  Lea's  Son  &  Co.'s  Publications— (ilfanwaZs). 


A  CENTURY  OF  AMERICAN  MEDICINE.  1776-1876.  By  Doctors  E.  H. 
-^^  Clarke,  H.  J.  Bigelow,  S.  D.  Gross,  T.  G.  Thomas  and  J.  S.  Billings.  Inone  very  hand- 
some 12mo.  volume  of  about  350  pages  :  cloth,  $2  25. 

This  work  appeared  in  the  pages  of  the  American  Journal  of  the  Medical  Sci«ncesduring  the 
year  1876.  As  a  detailed  account  of  the  development  of  medical  science  in  America,  by  gentle- 
men of  the  highest  authority  in  their  respective  departments,  the  professionwill  no  doubt  wel- 
come it  in  a  form  adapted  for  preservation  and  reference. 


-pj'EILL  {JOHN),  M.D.,  and     OMITH  {FRANCIS  G.),  M.D., 

Prof,  of  the  Institutes  of  Medicine  inthe  Univ.  of  Penna 

AN   Al^ALTTICAL    COMPENDIUM   OF   THE    VARIOUS 

BRANCHES  OF  MEDICAL  SCIENCE  ;  for  the  Use  and  Examination  of  Students.    A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  12mo. 
/  volume,  of  about  one  thousand  pages,  with  374  wood-cuts,  cloth,  $4  ;  strongly  bound  in 
leather,  with  raised  bands,  $4  75. 


E 


ARTSHORNE  {HENRY),  M.  D., 

Professor  of  Rygiene  in  the  University  of  Pennsytvania. 

A    CONSPECTUS    OF    THE   MEDICAL   SCIENCES;   containing 

Handbooks  on  Anatomy,  Physiology,  Chemistry,  Materia  Medica,  Practical  Medicine 
Surgery  and  Obstetrics.  Second  Edition,  thoroughly  revised  and  improved.  In  one  large 
royal  12mo.  volume  of  more  than  1000  closely  printed  pages,  with  477  illustrations  on 
wood.     Cloth,  $4  25  ;  leather,  $5  00. 


We  can  say  with  the  strictest  truth  that  it  is  the 
best  work  of  the  kind  with  which  we  areacquainted. 
It  embodies  in  a  condensed  form  all  recent  contribu- 
tions to  practical  medicine,  and  is  therefore  useful 
to  every  busy  practitioner  throughout  our  country, 
besides  being  admirably  adapted  to  the  use  of  stu- 
dents of  medicine.  The  book  is  faithfaliy  and  ably 
Q-KQC-aieA.— Charleston  Med.  Jotirn.,  April,  1875. 

The  work  is  intended  as  an  aid  to  the  medical 


student,  and  as  such  appears  to  admirably  fulfil  its  |  which  have  been  made  since  he  attended  lectures 


object  by  itsexcellent  arrangement,  the  fullcompi 
latioii  of  facts,  the  perspicuity  aud  terseness  of  Ian 
guage,  and  the  clear  and  instructive  illustrations 
in  some  parts  of  the  work. — American  Journ.  of 
Pharmacy,  Philadelphia,  July,  1874. 

The  volume  will  be  found  useful,  not  only  to  stu- 
dents, bat  to  manyothers  whomay  desire  torefresh 
their  memories  with  the  smallest  possible  expendi- 
ture of  time.— iV.  Y.  Med.  Journal,  Sept.  187-t. 

The  student  will  find  this  the  most  convenient  and 
useful  book  of  the  kind  on  which  he  can  lay  his 
hand. — Pacific  Med.  and  Surg.  Journ.,  Aug.  1874. 

This  is  the  best  book  of  its  kind  that  we  have  ever 
examined.  It  is  an  honest,  accurate,  and  concise 
eompend  of  medical  sciences,  as  fairly  as  possible 
representing  their  present  condition.  The  chan.ges 
and  the  additions  have  been  so  judicious  and  tho- 
rough as  to  render  it,  so  far  as  it  goes,  entirely  trust- 


worthy.   If  students  must  have  a  conspectus,  they 

will  be  wise  to  procure  that  of  Dr.  Hartshorne. 

Detroit  Rev.  of  Med.  and  Pharm. ,  Aug,  1874. 

The  work  before  us  has  many  redeeming  features 
not  possessed  by  others,  and  is  the  best  we  have 
seen.  Dr.  Hartshorne  exhibits  much  skill  in  con- 
densation. It  is  well  adapted  to  the  physician  in 
active  practice,  who  can  give  but  limited  time  to  the 
familiarizing  of  himself  with  the  important  changes 


The  manual  of  physiology  has  also  been  improved 
and  gives  the  most  comprehensive  view  of  the  latest 
advances  in  the  science  possible  in  the  space  devoted 
to  the  subject.  The  mechanical  execution  of  the 
book  leaves  nothing  to  be  wished  for. — Peninsular 
Journal  of  3fedieine,  Sept.  1874. 

After  carefully  looking  through  this  conspectus, 
we  are  constrained  to  say  that  it  is  the  most  com- 
plete work,  especially  in  its  illustrations,  of  its  kind 
that  we  have  seen. — Cincinnati  La.ncet,  Sept.  1874. 

The  favor  with  which  the  first  edition  of  this 
.Compendium  was  received,  was  an  evidence  of  its 
various  excellences.  The  present  edition  bears  evi- 
dence of  a  careful  and  thorough  I'e  vision.  Dr.  Harts- 
horne possesi^es  a  happy  faculty  of  seizing  upon  the 
salientpoints  of  each  subject,  and  of  presenting  them 
in  a  concise  and  yet  perspicuous  manner. — Leaven- 
worth Med.  Herald,  Oct.  1874 


T  UDLOW  {J.L.),  M.D. 
A   MANUAL   OF  EXAMINATIONS  upon  Anatomy,  Physiology, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy  and 
Therapeutics.  To  which  is  added  a  MedicalFormulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustrations  In  one  handsome  royal 
12mo.  volume  of  816  large  pages.  Cloth,  $3  25  ;  leather,  $3  75. 
The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suit- 
able for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 


mANNER  {THOMAS  HAWKES),  M.D.,  Sfc. 

^  A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAG- 

NOSIS.    Third  American  from  the  Second  London  Edition.    Revised  and  Enlarged  by 
Tilbury  Fox,  M.  D.,  Physician  to  the  Skin  Department  in  University  Collesre  Hospital, 
L3ndon,  <fcc.   In  oneneatVolume,  small  ]2mo.,  of  about  375  pages,  cloth,  $1  50. 
*ifc*  On  page  3,  it  will  be  seen  that  this  work  is  offered  as  a  premium  for  procuring  new 
subscribers  to  the  "American  Journal  of  the  Medical  Sciences." 


6  Henry  C.  Lea's  Son  &  Co.'s  Publications — {Anatomy). 

{IRAY  [HENRY),  F.R.S., 

\^  Lecturer  on  Anatomy  at  Si.  George's  Hospital,  London. 

ANATOMY,  DESCRIPTIVE    AXD  SURGICAL.     The  Drawings  by 

H.  V.  Carter,  M.D.,  and  Dr.  Westmacott.   The  Dissections  jointly  by  the  Author  and 
Dr.  Carter.      With   an   Introduction    on    General    Anatomy  and  Development  by  T 
Holmes,  M.A.,  Surgeon  to  St.   George's  Hospital.     A  new  American,  from  the  Eighth 
enlarged  ind  improved  London  edition.    To  which  is  added  the  Second  American  from  the 
latest  English  Edition  of  "  La.nr.marks.  Medical  and  Surgical,"'  by  Luther  Holdk.n, 
F.K.C.S.,  author  ot  "Human  Osteology,"   "A  Manual  ot  Dissections,"   etc.      In  one 
magnificent  imperial   octavo  volume  of  983  pages,  with  522  large  and  elaborate  engra\  - 
ings  on  wood.     Cloth,  $6  ;  leather,  raised  bands,  $7  j  half  Russia,  $7  50. 
The  author  has  endeavored  in  this  work  to  cover  a  more  extendearange  oisubjects  than  is  cus- 
tomary in  the  ordinary  te.xt-books,  by  giving  not  only  the  details  necessary  for  the  student,  but 
also  the  application  of  those  details  in  the  practice  of  medicine  and  surgery,  thus  rendering  it  both 
a  cuide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.   The  en- 
gravings form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
fio-uresof  reference,  with  descriptions  at  the  foot.  They  thus  form  a  complete  and  splendid  series, 
waich  will  greatly  assist  the  studentin  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  ttiose  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room  ;  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with 
a  thorou'^h  treatise  on  systematic,  descriptive  and  applied  Anatomy,  the  work  will  be  found  of 
essential  use  to  all  physicians  who  receire  students  in  their  offices,  relieving  both  preceptor  and 
pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

Since  the  appearance  of  the  last  American  Edition,  the  work  has  received  three  revisions  at  the 
hands  of  its  accomplished  editor,  Mr.  Holmes,  who  has  sedulously  introduced  whatever  has  seemed 
requisite  to  maintain  its  reputation  as  a  complete  and  authoritative  standard  text-book  and  work 
of  reference.  Still  further  to  increase  its  usefulness,  there  has  been  appended  to  it  the  recent 
work  by  the  distinguished  anatomist,  Mr.  Luther  Holden — "Landmarks,  Medical  and  teurgicul" 
which  gives  in  a  clear,  condensed  and  systematic  way,  all  the  information  by  which  the  prac- 
titioner can  determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work,  it  is  believed,  will  furnish  all  the  assistance  thatcan  berendered  by  typeand 
illustration  in  anatomical  study.  No  pains  have  been  spared  in  the  typographical  execution  of 
the  volume,  which  will  be  found  in  all  respects  superior  to  former  issues.  Notwithstanding  th« 
increase  of  size,  amounting  to  over  100  pages  and  57  illustrations,  it  will  be  kept,  as  heretofore, 
at  a  price  rendering  it  one  of  the  cheapest  works  ever  offered  to  the  American  profession. 

The  recent  work  of  Mr.  Holden,  which  was  no-    to   consult   his  books  on    anatomy.    The   work   is 
ticed  by  us  on  p.  53  of  this  volame,  has  been  added  i  simply  indi.spensable.  especially  this  pre-ent  Amer- 
a-  an  appendix,  so  that,  altogether,  this  is  the  most  I  icaa  edition.— Fa.  Jifed.  Mojithly,  Sept.  1878. 
practical  and  complete  aaatomical  treatise  available  '•  addition  of  the  recent  work  of  Mr.  Holden, 

to  American  students  and  phy->c.an»      The    ortQer  1  appendix,  renders  this  the  most  practical  and 

flods  in  It  the  necessary  ffnide  in  making  dissec-  ,  .         •  i   i,i     .      «         •  j      . 

nous  ju  11  luc  uc  c        J  j>         „i,,„,^_  „„    „;„„.„    comp  ete   treatise  available  to  American  students, 
tions'   a   verv   comp^eheD^lve   chapter  on    minute        v  ^    j   •      ..  v.        •  u      .  ■       . 

iiuuo,   a    .C.J    V       y    .„,K...„„„   .1  ,„„„!,,  i,ir„  ^„     who  find  in  It  a  comprehensive  chapter  on  minne 
anatomy :  and  about  all  that  can  be  taught  him  on  u      .     n  .i     .  v     .        u.  i 

anaiom/  ,  auu  a  ,„„_.  ~»,ii.»  .v,l   lut.o,  in     anatomy,  about  all  that  can  be  taught  on  general 

general  and  special  anatomy     while  the  latter,  in  ' ".  ,.,      ..     .     °.  .     ,         , 

eueiai  auu  oyc  „/,.'.,     „,„,^<.i  r,„ini  r,f    aud  special  anatomy,  while  its  treatment  of  each 

treatment  ot  each  return  irom  a  surgical  point  ol  ■         .     *^  .  .     i        -    .     *     .         .      .\_  » 

ireaimcui  1.1  CO,  s        j  !.,;„„  .,xfr    u^M^n      region,  from  a  surgical  point  of  view,  in  the  valu- 

iluable  iidditionof  Mr.  Holden,     „.»„'„,;„„  ^„  w,*„„,^^„  ;„  oii  ,i,o,  ;^;ii  v,„  =o.„„_ 


view,  and  in  the  val 

will   find  all  that  will  be  essential  to  him  in  his 

practice —..Veii!  Remed-es,  Aug   1S7S. 

This  work  Is  as  near  perfection  as  one  could  pos- 
sibly or  reasonably  expect  any  book  intended  as  a 


able  section  by  Mr.  Holden, is  all  that  will  be  essen- 
tial to  them  in  practice. — Ohio  Medical  Recorder, 
Aug   1S78. 

It  is  difficult  to  speak  in  moderate  terms  of  this 


text-book  or  a  genera)  reference  book  on  anatomy  ]  new  edition  of  "  Gray."  It  seems  to  be  as  nearly 
to  be.  The  American  publisher  deserves  the  thanks  perfect  as  it  is  possible  to  make  a  book  devoted  to 
of  the  profession  for  appending  the  recent  work  of  any  branch  of  medical  science.  The  labors  of  the 
Mr.  Holden, '•  irtrirfrnflfrfc*,  J)f«d!cai<7?irfS'»r^ica/,"  '  eminent  men  who  have  successively  revised  the 
which  has  already  been  commended  as  a  separate  '  eight  editions  through  which  it  has  passed,  wonld 
book.  The  latter  work — treating  of  topographical  seem  to  leave  nothing  for  fntnre  editors  to  do.  The 
anatomy— has  become  an  essential  to  the  library  of  I  addition  of  Holden's  "  Landmarks"  will  make  it  as 
every  intelligent  practitioner.  We  know  of  no  indispensable  to  the  practitioner  of  medicine  and 
book  that  can  take  its  place,  written  as  It  is  by  a  1  gnrgery  as  it  has  been  heretofore  to  the  student.  As 
most  distinguished  anatomist.  It  would  be  simply  regards  completeness,  ease  of  reference,  utility, 
a  waste  of  words  to  say  anything  further  in  praise  beauty,  and  cheapness,  it  has  no  rival.  No  stu- 
of  Gray's  Anatomy,  the  text-book  in  almost  every  ;  dent  should  enter  a  medical  school  without  it ;  no 
medical  college  in  this  country,  and  the  daily  refer- I  physician  can  afford  to  have  it  absent  from  hia 
ence  book  of  every  practitioner  who  has  occasion  i  library. — St.  Louis  Clin.  Record,  Sept.  1S78. 

Also  for  sale  separate — 
TTOLDEN  {LUTHER),  F.R.C.S., 

J- J-  Surgenn  toSt.  Bartholomew' s  and  the  Foundling  Ho.'ipitnls. 

LANDMARKS,  MEDICAL  AND    SURGICAL.     Second   American, 

from  the  Latest  Revised  English  Edition,  with  additions  by  W.  W.  Keen,  M.D.,  Prof,  of 
Artistic  Anatomy  in  the  Penna.  Academy  of  the  Fine  Arts,  formerly  Lecturer  on  Anat- 
omy in  the  Phila.  School  of  Anatomy.  In  one  handsome  12mo.  volume,  of  about  140 
pages.     Cloth,  $1.00.      {Just  Ready.) 

TIE  ATE  (CHRISTOPHER),  F.R.C.S., 

''-'-  Teacher  of  Operative  Surgery  in  University  College,  London. 

PRACTICAL  ANATOMY:    A  Manual  of  Dissections.     From  the 

Second  revised  and  improved  London  edition.  Edited,  with  additions,  by  W.  W.  Keen, 
M.  D.,  Lecturer  on  Pathological  Anatomy  in  the  Jefferson  Medical  College,  Philadelphia. 
In  one  handsome  royal  12 mo. volume  of  578  pages,  with  24  7iIlustration8.  Cloth,  $3  50  ; 
leather,  $4  00. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Anatomy).  7 

A  LLEN  (HARRISON),  M.D. 

^1  Profesior  of  Physiology  in  the  Univ.  of  Pa. 

A  SYSTEM  OF  HUMAN  ANATOMY:  INCLUDING  ITS  MEDICAL 

and  Surgical  Relations.  For  the  Use  of  Practitioners  and  Studentsof  Medicine.   With  iin 
Introductory  Chapter  on  Histology.  ByE.O.  Shakespeare,  M  D.,  Ophthalmologistto  the 
Phila.  Hosp.    In  one  large  and. handsome  quarto  volume,  with  several  hundred  original 
illustrations  on  lithographic  plates,  and  numerous  wood-cuts  In  the  text.      (Shortly.) 
In  this  elaborate  work,  which  has  been  inactive  preparation  for  several  years,  the  author  has 
Bought  to  give,  not  only  the  details  of  descriptive  anatomy  in  a  clearand  condensed  form,  but  also 
the  practical  applications  of  the  science  to  medicine  and  surgery.  The  work  thus  has  claims  upon 
the  attention  of  the  general  practitioner,  as  well  as  of  the  student,  enabling  him  not  only  to  re- 
fresh his  recollections  of  the  dissecting  room,  but  also  to  recognize  thesignificance  of  allvaria- 
tions  from  normal  conditions.     The  marked  utility  of  the  object  thus  sought  by  the  author  is 
self-evident,  and  his  long  experience  and  assiduous  devotion  to  its  thorough  development  are  a 
sufBcient  guarantee  of  the  manner  in  which  his  aims  have  been  carried  out.  No  pains  have  been 
spared  with  the  illustrations.  Those  of  normal  anatomy  are  from  original  dissections,  drawn  on 
stone  by  Mr.  Hermann  Faber,  with  the  name  of  every  part  clearly  engraved  upon  the  figure 
after  the  manner  of  "  Holden"  and  "  Gray, "  and  in  every  typographical  detail  it  will  be  the 
effort  of  the  publishers  to  render  the  volume  worthy  of  the  very  distinguished  position  which  is 
anticipated  for  it. 

PILIS  {GEORGE   VINER). 

-*-^  Emeritus  Professor  nf  Anatomy  in  University  College,  London. 

DEMONSTRATIONS  OP  ANATOMY;  Being  a  Guide  to  the  Know- 

ledge  of  the  Human  Body  by  Dissection.  By  George  Vtner  Ellis,  Emeritus  Professor 
of  Anatomy  in  University  College,  London.  From  the  Eighth  and  Revised  London 
Edition.  In  one  very  handsome  octavo  volume  of  over  700  pages,  with  266  illustrations. 
Cloth,  $4.25  I  leather,  $6.25.      {Lately  Issued.) 

This  work  has  long  been  known  in  England  as  the  leading  authority  on  practical  anatomy, 
and  the  favorite  guide  in  the  dissecting-room,  as  is  attested  by  the  numerous  editions  through 
which  it  has  passed.  In  the  last  revision,  which  has  just  appeared  in  London,  the  accomplished 
author  has  sought  to  bring  it  on  a  level  with  the  most  recent  advances  of  science  by  making  the 
necessary  changes  in  his  account  of  the  microscopic  structure  of  the  different  organs,  as  devel- 
oped by  the  latest  researches  in  textural  anatomy. 

Ellis's  Demonstrations  is  the  favorite  text-book  ]  its  leadership  over  the  English  manuals  upon  dis- 
of  the   English   student   of  anatomy.     In  passing    secting. — Phila.  Med.  Times,  May  24,  1879. 
through  eight  editions  it  has  been  so  revised  and  1 

adapted  to  the  needs  of  the  student  that  it  would  i  -^^  a  dissector,  or  a  work  to  have  in  hand  and 
seem  that  it  had  almost  reached  perfection  in  this  '  studied  while  one  is  engaged  in  dissecting,  we  re- 
special  line.  The  descriptions  are  clear,  and  the  :  S'^''^  *'  as  the  very  best  work  extant,  which  is  cer- 
methods  of  pursuing  anatomical  investigations  are  '  tainly  saying  a  very  great  deal.     As  a  text-book  to 


given  with  such  detail  that  the  book  is  honestly 
entitled  to  its  name. — St.  Louis  Clinical  Record, 
June,  1879. 

The  success  of  this  old  manual  seems  to  be  as  well 
deserved  in  the  present  as  in  the  past  volumes. 
The  book  seems  destined  to  maintain  yet  for  years 


be  studied  in  the  dissecting-room,  it  is  superior  to 
any  of  the  works  upon  a-tmiomj .— Cincinnati  Med. 
News,  May  21,  1879. 

We   most  unreservedly  recommend   it  to   every 

practitioner  of  medicine  who  can  possibly  get  it. 

Va.  Med.  Monthly,  June,  1879. 


w 


JLSON  (ERASMUS),  F.R.S. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  SpeciaL  Edited 

by  W.  H.  GoBEECHT,  M.D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  Col- 
lege of  Ohio.  Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood.  In 
one  large  and  handsome  octavo  volume,  of  over  600  pages  ;  cloth,  $4  ;  leather,  $6. 

gMITE  {HENRY H.),  M.D.,         and  JJORNER  {  WILLIAM  E.),M.D., 

Prof  .of  Surgery  inthe  Univ.  of  Penna.,&c.  Late  Prof,  of  Anatomy  in  the  Univ.  ofPenna. 

AN   ANATOMICAL   ATLAS  ;    Illustrative  of  the  Structure  of  the 

Human  Body.  In  one  volume,  large  imperial  octavo,  cloth,  with  about  six  hundred  and 
fifty  beautiful  figures.     $4  50. 

CHAFER  {ED  WARD  ALBERT),  M.D., 

Assistant  Profetsor  of  Physiology  in  University  College,  London. 

A  COURSE  OF  PRACTICAL  HISTOLOGY:  Being  an  Introduction  to 

the  Use  of  the  Microscope.  In  one  handsome  royal  12mo.  volume  of  304  pages,  with 
numerous  illustrations:  cloth,  $2  00.     (Lately  Issued.) 


s 


HOENER'S  SPECIAL   ANATOMY  AND   HISTOL- ,      for  their  Pass  Examination.   With  engravings  on 
06T.    Eighth  edition,  extensively  revised   and  ;      wood.     In   one   handsome   royal  12mo.  volume, 
modified-     In  2  vols.   8vo.,  of  over  1000  pages,  {      Cloth,  $2  2,5. 
with  .320  wood-cuts  :  cloth,  $6  00  !  CLELAND'S  DIRECTORY  FOR  THE  DISSECTION 

SHARPEY    AND    QUAIN'S    HUMAN     ANATOMY.!      OF  THE  HUMAN  BODY.     In  one  small  volume 


Revised,  by  Joseph  Leidt,  M.D.,Prof  of  Aaat. 
in  Duiv.  of  Penn.  In  two  octavo  vols,  of  about 
1300  pages,  with  .511  illustrations  Cloth,  $6  00. 
BELLAMYS  STUDENT'S  GUIDE  TO  SURGICAL 
ANATOMY  :  A  Text-book  for  Students  preparing 


royal  12mo.  of  132  pages:  eloth  *1  25. 
HAKTSHORNE'S  HANDBOOK  OF  ANATOMY  AND 
PHYSIOLOGY.  Second  edition,  revised.  In  one 
royal  12mo.  vol.,  with  220  woodcuts;  cloth 
*1  75. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Physiology). 


fkALTON  {J.  C),  M.D., 

•*-f  Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  Torl(,&e. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY.    Designed  for  the  use 

of  students  and  Practitioners  of  Medicine.  Seventh  edition,  thoroughly  revised  and  rewrit- 
ten, with  about  three  hundred  and  sixty  illustrations  on  wood.  In  one  very  beautiful 
octavo  volume,  of  about  900  pages.     {Neaiiy  Ready.) 


A  few  notices  of  the  previous  edition  are  appe 
Prof.  Dalton  ha.s  discu.s.'ied  conflictiuf^  theories  and 
conclusions  regarding  phyfiiological  quustious  with  a 
fairnes.s,  a  fulness,  and  a  concisenes.s  which  lend  fresh- 
ness and  vigor  to  the  entire  book.  But  his  discussions 
have  been  so  guarded  by  a  refusal  of  admission  to  those 
speculative  and  theoretical  explanations,  which  at  best 
exist  in  the  mindsof  observers  themselves  as  only  pro- 
babilities, that  none  of  his  readers  need  be  led  into 
grave  errors  while  making  them  a  study  .—TAe  Medical 
/Jecord,  Feb.  19, 1876. 

For  clearness  and  perspicuity,  Daltoii's  Physiology 
commended  itself  to  tlie  student  years  ago,  and  was  a 
pleasant  relief  from  the  verbose  productions  which  it 
supplanted.  Physiology  has,  however,  made  many  ad- 
vances since  then— and  while  the  style  has  been  pre- 
served intact,  the  work  in  the  present  edition  has  been 
brought  up  fully  abreastof  the  times.  Thenew  chemical 
nolation  and  nomenclature  have  also  been  introduced 
into  the  present  edition.    Notwithstanding  the  multi- 


nded. 

plicity  of  text-books  on  physiology, this  will  lose  none 
of  its  old  time  popularity.  The  mechanical  execution 
of  the  work  is  all  that  could  be  desired. — Petiinsular 
Journal  of  Mexlicine,  Dec.  1875. 

This  popular  text-book  on  physiology  comes  to  us  in 
i  ts  sixth  edition  with  the  addition  of  about  fifty  per  cent, 
of  new  matter,  chiefly  in  the  departments  of  patho- 
logical chemistry  and  the  nervous  system,  where  the 
principal  advances  have  been  realized.  With  so  tho- 
rough revision  and  additions,  that  keep  the  work  well 
up  to  the  times,  its  continued  popularity  may  be  confi- 
dently predicted,  notwithstanding  the  competition  it 
may  encounter.  The  publisher's  work  is  admirably 
done. —  St.  Louis  Med.  and  Surg.  Journ.,  "Dec.  1875. 

The  revision  ofthis  great  work  has,brought  it  forward 
with  the  physiological  advances  of  thed.ay,  and  renders 
it,  as  it  has  ever  been,  the  finest  work  for  studenlses- 
tant. — JVashville  Journ.of  Med.  and  Surg.,  Jan.  1876. 


pARPENTER  (  WILLIAM  B.),  M.  D.,  F.  R.  S.,  F.O.S.,  F.L.S., 

v^*  Registrar  to  University  of  London,  etc 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  Edited  by  HenryPower, 

M.B.  Lond.,  F.R.C.S.,  Examiner  in  Natural  Sciences,  University  of  Oxford.  Anew 
American  from  the  Eighth  Revised  and  Enlarged  English  Edition,  with  Notes  and  Addi- 
tions, by  Francis  G.  Smith,  M.D.,  Professor  ol  thelnstitutescf  Medicinein  the  Univer- 
sity of  Pennsylvania,  etc.  In  one  very  large  andhandsome  octavo  volume,  of  1083  pages, 
with  two  plates  and  373  engs.  on  wood.  Cloth,  $5  50  ;  leather,  $6  50;  half  Russia,  $7. 
We  have  been  agreeably  surprised  to  And  the  vol- 1  new  a  year  or  two  ago,  looks  now  as  if  it  had  been  a 


nnie  so  complete  in  regard  to  the  structure  and  func- 
tions of  the  nervous  system  in  all  its  relations,  a 
subject  that,  in  many  respects,  is  one  of  the  most  diffi- 
cult of  all,  in  the  whole  range  of  physiology,  upon 
which  to  produce  a  full  and  satisfactory  treatise  of 
the  class  to  which  the  one  before  us  belongs.  The 
additions  by  the  American  editor  give  to  the  work  as 
it  is  a  considerable  value  beyond  that  of  the  last 
English  edition.  In  conclusion,  we  can  give  our  cor- 
dial recommendation  to  the  work  as  it  now  appears. 
The  editors  have,  with  their  additions  to  the  only 
work  on  physiology  in  our  language  that,  in  the  full- 
est sense  of  the  word,  is  the  production  of  a  philo.so- 
pher  as  well  as  a  physiologist,  brought  it  up  as  fully 
as  could  be  expected,  if  not  desired,  to  the  standard 
of  our  knowledge  of  its  subject  at  the  present  day. 
It  will  deservedly  maintain  the  place  it  has  always 
Had  iu  the  favor  of  the  medical  profession. — Journ. 
of  Nervons  and  Mental  Disease,  April,  1877. 

Suchenormousadvances  havereceutlybeenmadein 
our  physiological  knowledge,  that  what  was  perfectly 


received  and  established  fact  for  years.  In  this  ency- 
clopaedic way  it  is  unrivalled.  Here,  as  it  seems  to 
us,  is  the  great  value  of  the  book;  one  is  safe  in  sending 
a  student  to  it  for  information  on  almost  any  given 
subject,  perfectly  certain  of  the  fulness  of  information 
it  will  convey,  and  well  satisfied  of  the  accuracy  with 
which  it  will  there  be  found  stated. — London  Med. 
Times  and  Gazette,  Feb.  17, 1877. 

Themeritsof  "Carpenter's  Physiology" are  so  widely 
known  and  appreciated  that  we  need  only  allude  briefly 
to  thefact  that  in  thelatest edition  vvillbefound  a  com- 
prehensive embodiment  of  the  results  of  recent  physio- 
logical investigation.  Care  has  been  taken  to  preserve 
the  practical  character  of  the  original  work.  In  fact 
the  entire  work  has  been  brought  up  to  date,  and  bears 
evidence  of  the  amount  of  labor  that  has  been  bestowed 
upon  it  by  its  ilistinguishod  editor,  Mr.  Henry  Power. 
The  American  editor  has  made  the  latest  additions,  in 
order  fully  to  cover  the  time  that  has  elapsed  since  the 
last  English  edition.— iV.  y.  Med.  Journal,  Ja.n.lSI't . 


fpOSTER  {MICHAEL),  M.D.,  F.R.S., 

J-  Prof,  of  Physiology  in  Cambridge  Univ.,  England 

TEXT-BOOK  OF  PHYSIOLOGY.    Second  American  from  tlie  Latest 

English  Edition.  Edited,  with  Extensive  Notes  and  Additions,  bv  Edwaud  T.  Reichert, 
M.D.,  Late  Demonstrator  of  Experimental  Therapeutics  in  the  liniv.  of  Penna.  In  one 
handsome  royal  12mo.  volume  of  about  1000  pages,  with  260  illustrations.  Cloth,  $3  25  ; 
leather,  $3  75.      {J7ist  Ready.) 

In  the  prep:>ration  of  a  second  American  edition  of  Mr.  Foster's  Physiology,  the  editor  has 
endeavored  to  render  it  more  than  ever  acceptable  to  the  student  as  a  clear  and  comprehensive 
text  book,  presenting  the  science  in  its  latest  developments.  The  original  work  being  an  e.x- 
position  of  abstract  physiology  without  any  reference  to  the  details  of  physiological  anatomy, 
it  seemed  desirable  to  introduce  some  account  of  structure,  in  order  to  render  more  intellii^i'- 
ble  to  the  student  the  views  and  theories  of  the  science.  This  the  editor  has  added  in°as 
concise  a  manner  as  possible;  and  in  aid  of  this  end  has  freely  introduced  illustration's  Irom 
recognized  authorities. 


LEHMANK'S  MANUAL  OF  CHEMICAL  PHTSIOL-i  LEHMANN'SPHTSIOLOGICALCHEMISTRY  Com- 
"*^7;  ..J-'i^"^^''^®'^  /'''r^""  ^^^  German,  with  Notes  ]      plete  in  two  large  octavo  volumes  of  1200  papes, 
andAdditions,  by  J.  Cheston  Morris,  M.D.   Will        with  200 illustrations;  cloth  $6 
illustrations  on  wood.     In  one  octavo  volume  of  i  ' 

336  pages.     Cloth,  $2  25. 


Henry  C.  Lea's  Son  &  Co.'s  Publications— (C^emtsi!r?/). 


A  TTFIELD  {JOHN),  Ph.D., 

■^^  Professor  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Great  Britain,  &c . 

CHEMISTRY,  GENERAL,  MEDICAL  AND  PHARMACEUTICAL; 

Including  the  Chemistry  of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the  General  Principles 
of  the  Science,  and  their  Application  to  Medicine  and  Pharmacy.  Eighth  edition,  revised 
by  the  author.  In  one  handsome  royal  12mo.  volume  of  700  pages,  with  illustrations. 
Cloth,  $2  50  ;  leather,  $3  00.      {Now  Ready.) 


We  have  repeatedly  expressed  our  favorable 
opinion  of  this  work,  and  on  the  appearance  of  a 
new  edition  of  it,  little  remains  for  us  to  say,  ex- 
cept that  we  expect  this  eighth  edition  to  "he  as 
indispensable  to  us  as  the  seventh  and  previous 
editions  have  been.  While  the  general  plan  and 
arrangement  have  been  adhered  to,  new  matte 


of  chemistry  in  all  the  medical  colleges  in  the 
United  States.  The  present  edition  contains  such 
alterations  and  additions  as  seemed  necessary  for 
the  demonstration  of  the  latest  developments  of 
chemical  principles,  and  the  latest  applications  of 
chemistry  to  pharmacy.  It  is  scarcely  necessary 
for  lis  to  say  that  it  exhibits  chemistry  in  its  pre- 


has  been  added  covering  the  observations  made  |  sent  advanced  state. — Oincinnati  Medical  News, 
since  the  former  edition.     The  present  differs  from    April,  1S79. 

the  preceding  one  chiefly  in  these  alterations  and  |  The  popularity  which  this  work  has  enjoyed  is 
in  about  ten  pages  of  useful  tables  added  in  the  owing  to  the  original  and  clear  disposition  of  the 
appendix. -4m.  Jonrn.  of  Pharmacy,  May,  1879.      !  facts  of  the  science,  the  accuracy  of  the  details,  and 

A  standard  work  like  Attiield's  Chemistry  need  i  the  omission  of  much  which  freights  many  treatises 
only  be  mentioned  by  its  name,  without  further  heavily  without  briugingcorrespondinginstruction 
comments.  The  present  edition  contains  such  al-  to  the  reader.  Dr.  Attfield  writes  for  students,  and 
terations  and  additions  as  seemed  necessary  for  i  primarily  for  medical  students;  he  always  has  an 
the  demonstration  of  the  latest  developments  of'  eye  to  the  pharmacopoeia  and  its  officinal  prepara- 
chemical  principles,  and  the  latest  applications  of  tions;  and  he  is  continually  putting  the  matter  in 
chemistry  to  pharmacy.  The  author  has  bestowed  the  text  so  that  it  responds  to  the  questions  with 
arduous  labor  on  the  revision,  and  the  extent  of  which  each  section  is  provided.  Thus  the  student 
the  information  thus  introduced  may  be  estimated  learns  easily,  and  can  always  refresh  and  test  his 
from  the  fact  that  the  index  contains  three  hun- ,  knowledge. — Med.  andSurg. Reporter,  A-pTill9,'79. 
dred  new  references  relating  to  additional  mater-  :  -vye  noticed  onlv  about  two  vears  and  a  half  ago 
M  f^'-q^^^*  *  ^^^''^^'^''  "''^'^  Chemical  Gazette,  the  publication  of  the  preceding  edition,  and  re- 
May,  lb/9.  1  marked  upon  the  exceptionally  valuable  character 

This  very  popular  and  meritorious  work  has  j  of  the  work.  The  work  now  iocludes  the  whole  of 
now  reached  its  eighth  edition,  which  fact  speaks  the  chemistry  of  the  pharmacopoeia  of  the  United 
in  the  highest  terms  in  commendation  of  its  excel-  States,  Great  Britain,  and  India. — New  Rem,edie8, 
lence.     It  has  now  become  the  principal  text-book  i  May,  1879. 


o 


REENE  [WILLIAM  H.),  M.D., 

Deraonstmtor  of  Chemistry  in  Med.  Bept.,  TTniv.  of  Penna,. 

A  MANUAL  OF  MEDICAL  CHEMISTRY.    For  the  Use  of  Students. 

Based  upon  Bowman'.s  Medical   Chemistry.     In   one  royal  12mo.  volume  of  312  pages 
With  illustrations.     Cloth,  SI  75.     {Now  Ready.) 

It  is  well  written,  and  gives  the  latest  views  on  I  The -little  work  before  us  is  oue  which  we  think 
vital  chemistry,  a  subject  with  which  most  physi-  will  be  studied  with  pleasure  and  profit.  The  de- 
dans are  not  sufficiently  familiar.  To  those  who  scriptions,  though  brief,  are  clear,  and  in  most  cases 
may  wish  to  improve  their  knowledge  in  that  direc-  sufficient  for  the  purpose.  This  book  will,  in  nearly 
tion,  we  can  heartily  recommend  this  work  as  being  all  cases,  meet  general  approval. — Am.  Journ.  of 
worthy  ofacarefulperusal. — Phila.  Med.  and  Surg.  Pharmacy,  April,  1880. 
Reporter,  April  2i,  1880.  I 


ffLASSEN  {ALEXANDER), 

^-^  Professor  in  the  RoyaJ  Polytechnic  School,  Aix-la-Chapelle. 

ELEMENTARY   QUANTITATIVE    ANALYSIS.     Translated  with 

notes  and  additions  by  Edgar  F.  S-MITH,  Ph.D.,  Assistant  Prof,  of  Chemistry  in  the 
Towne  Scientific  School,  Univ.  of  Penna.  In  one  handsome  royal  12mo.  volume,  of  324 
pages,  with  illustrations  ;  cloth,  $2  00.      {Lately  Issued.) 

It  is  probably  the  best  manual  of  an  elementary  ]  advancing  to  the  analysis  of  minerals  and  such  pro- 
nature  extant,  insomuch  as  its  methods  are  the  best,  ducts  us  are  met  with  in  applied  chemistry.  It  is 
It  teaches  by  examples,  commencing  with  single  '  an  indispecsable  book  for  students  in  chemistry.—" 
determinations,  followed  by  separations,  and  then  ,  Boston  Journ.  of  Qhernistry,  Oct.  1878. 

riALLO WAY  {ROBERT),  F.C.S., 

^-^  Prof,  of  Applied  Ohemi-i-try  in  the  Royal  College  of  Science  for  Ireland,  etc. 

A  MANUAL  OF  QUALITATIVE  ANALYSIS.  From  the  Fifth  Lon- 
don Edition.    In  one  neat  royal  12mo.  volume,  with  illustrations  ;  cloth,  $2  75. 

T?EMSEN{IRA),  M.D.,  Ph.D., 

Professor  of  Cherai-itry  in  the  Johns  Hopkins  University,  Baltimore. 

PRINCIPLES  OF  THEORETICAL  CHKMISTRY,  with  special  reference 

to  the  Constitution  of  Chemical  Compounds.  In  one  handsome  royal  12mo.  vol.  of  over 
232  pages:  cloth,  $1  50. 


BOWMAN'S  INTRODUCTION  TO  PRACTICAL 
CHEMISTRY,  INCLUDING  ANALYSIS.  Sixth 
American,  from  the  Sixth  and  revised  London  edi- 
tion. With  numerous  illustrations.  In  one  neat 
vol.,  royal  12mo.,  cloth,  $2  25. 


WOHLER  AND  FITTIG'S  OUTLINES  OF  ORGANIC 
CHEMISTRY.  Tran.slated,with  additions,  from  the 
Eighth  German  Edition.  By  Ira  Remsex.  M  D., 
Ph  D.,  Prof,  of  Chemistry  and  Physics  in  Williams 
College,  Mass.  In  one  volume,  royal  12mo.  of  550 
pp.,  cloth,  $3. 


10 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Chemistry). 


pOWNES  [GEORGE),  Ph.D. 

A  MANUAL  OF  ELEMENTARY  CHEMISTRY;  Theoretical  and 

Practical.  Revised  and  corrected  by  Henry  Watts,  B.  A.,  F  R.S.,  author  of  "A  Diction- 
ary of  Chemistry,"  etc.  With  a  colored  plate,  and  one  hundred  and  seventy -seven  illus- 
trations. A  new  American,  from  the  Twelfth  and  enlarged  London  edition.  Edited  by 
Robert  Bridges,  M.D.  In  one  larpe  royal  12mo.  volume,  of  over  1000  pages; 
cloth,  $2  75  ;  leather,  $3  25.     (Lately  Issued.) 


This  work,  inorganic  and  organic,  is  complete  in 
one  convenient  volume.  In  its  earliest  editions  it 
was  fully  up  to  the  latest  advancements  and  theo- 
ries of  that  time.  In  its  present  form,  it  presents, 
in  a  remarkably  convenient  and  satisfactory  raan- 
nt-r,  the  principles  and  leading  facts  of  the  chemistry 
of  to-driy.  Concerning  the  manner  in  which  the 
various  bubjects  are  treated,  much  deserves  to  be 
said,  and  mostly,  loo,  in  praise  of  thK  book.  A  re- 
view of  such  a  work  as  FouniKs's  Chewi-itry  within 
the  limits  of  a  book-notice  for  a  medical  weekly  is 
simply  out  of  the  question. — Cineinnnti  Lancet  and 
Clinic,  D^c.  14, 1S78. 

When  we  state  that,  in  our  opinion,  the  present 
edition  sustains  in  every  respect  the  high  reputation 
which  its  predecessors  have  acquired  and  euj.)yed, 
we  express  therewith  our  full  belief  in  its  intrinsic 
value  as  a  text-book  and  work  of  reference. — Am. 
Journ.  of  Pharm.,  Aug.  1878. 

The  conscientious  care  which  has  been  bestowed 
upon  it  by  the  American  and  English  editors  renders 
It  still,  perhaps,  the  best  book  for  the  student  and  the 
practitioner  who  would  keep  alive  the  acquisitions 
of  his  student  days.    It  has,  indeed,  reached  a  some- 


what formidable  magnitude  with  its  more  than  a 
thousand  pages,  but  with  less  than  this  no  fair  repre- 
sentation of  chemistry  as  ii  now  is  can  be  given.  The 
type  is  small  but  very  clear,  and  the  sections  are  very 
lucidly  arranged  to  facilitate  study  and  reference. — 
Mud    and  Surg.  Rf-portfr,  Aug   3,  1878. 

The  work  is  too  well  known  to  American  students 
to  need  any  extended  notice;  suffice  it  to  say  that 
the  re vi>ion  by  the  English  editor  has  been  faithfully 
done,  and  that  Professor  Bridges  has  added  some 
fresh  and  valuable  matter,  especially  in  the  inor- 
ganic chemistry.  Th.e  book  has  always  been  a  fa,- 
vorite  in  this  country,  and  in  its  new  shape  bids 
fair  to  retain  all  its  former  prestige. — Boston  Jour, 
of  Chemistry,  Aug.  IS78. 

It  will  be  entirely  unnecessary  for  us  to  make  any 
remarks  relating  to  the  general  characterof  Fownes' 
Manual.  For  over  twenty  years  it  has  held  the  fore- 
most place  as  a  text-book,  and  the  elaborate  and 
thorough  revisions  which  have  been  made  from  time 
to  timeleavelittlechance  for  any  wideawaherival  to 
step  before  it. — Canadian  Pharm.  Jour.,  Aug.  1878. 

As  a  manual  of  chemistry  it  is  without  a  superior 
in  the  language. — Md.  Med.  Jour.,  Aug.  1878. 


B 


LOXAM  {G.L.), 

Profenaor  of  Chemistry  in  King''  s  College,  London. 

CHEMISTRY,  INORGANIC  AND  ORGANIC. 


Prom  the  Second  Lon- 


don Edition.     In  one  very  handsome  octavo  volume,  of  700  pages,  with  about  300  illus- 
trations.    Cloth,  $4  00 ;  leather,  $5  00. 


We  havein  this  work  a  complete  and  most  excel- 
lent text-book  for  the  use  of  schools,  and  can  heart- 
ily recommend  it  as  such. — Boston  Med.  and  Surg. 
Journ.,  May  28,  1874. 

Theabovelsthe  titleof  a  work  which  we  can  most 
conscientiously  recommend  to  students  of  chemis- 
try. It  is  as  easy  as  a  work  on  chemistry  could  be 
made,  at  thesame  time  that  it  presentsa  full  account 
of  thatscience  as  it  now  stands.  We  have  spoken 
of  the  work  as  admirably  adapted  to  the  wants  of 
students  ;  it  is  quite  as  well  suited  to  the  require- 
ments of  practitioners  who  wish  to  review  their 
chemistry,  or  have  occasion  to  refresh  their  memo- 
ries on  any  point  relating  to  It.  In  a  word,  it  is  a 
book  to  be  read  by  all  who  wish  to  know  what  is 
thechemistry  of  the  preaentday. — American  Prac- 
titioner, Nov.  18T3. 


It  would  be  difiBcult  for  a  practical  chemist  and 
teacher  to  find  any  material  fault  with  this  most  ad- 
mirable treatise  The  author  has  given  ns  almost  a 
cyclopaedia  within  the  limits  of  a  convenient  volume, 
and  has  done  so  without  penning  the  useless  para- 
graphs too  commonly  making  up  a  great  pan  of  the 
bulk  of  many  cumbrous  works.  The  progressive 
scientist  is  not  disappointed  when  he  looks  for  the 
record  of  new  and  valuable  processes  and  discover- 
ies, while  the  cautious  conservati»'e  doe.s  not  find  its 
pages  monopolized  by  uncertain  theories  and  specu- 
larions.  A  peculiar  point  of  excellence  is  the  crys- 
tallized form  of  expression  in  which  great  truths  are 
expressed  in  very  short  paragraphs.  One  is  surprised 
at  the  brief  space  allotted  to  an  important  topic,  and 
yet,  after  reading  it,  he  feels  that  little,  if  any  more 
should  have  been  said.  Altogether,  it  is  seldom  yoa 
see  a  text-book  so  nearly  faultless. —  Cincinnati 
Lancet,  Nov.  1873. 


rfLOWES  {FRANK),  D.Sc.  London. 

^^  Senior  Science- Mn. iter  at  the  HighSchool,  Newcastle-under-Lyme,  etc. 

AN  ELEMENTARY  TREATISE  ON  PRACTIC  \L  CHEMISTRY 

AND  QUALITATIVE  INORGANIC  ANALYSIS.  Specially  adapted  for  Use  in  the 
Laboratories  of  Schools  and  Colleges  and  by  Beginners.  Second  American  from  the 
Third  and  Revised  English  Edition.  In  one  very  handsome  royal  12mo.  volume  of 
372  pages,  with  47  illustrations.     Cloth,  $2  50.      {Just  Ready.) 


This  is  a  valuable  work  for  those  about  to  com- 
mence chemistry,  the  more  so  as  by  its  use  they  are 
simultaneously  acquainted  with  the  manipulation 
of  chemical  analysis,  a  method  which  is  the  most 
valuable  to  impart  a  thor^'^ugh  knowle<ige  of  chemis- 
try. It  is  a  very  good  little  book,  and  will  make 
for  itself  manv  warm  friends  and  supoorters.  It 
treats  the  subject  well  and  the  tabl-s  are  very  clear 
and  valuable. — St.  Louis  Med.  and  Surg.  Journ., 
Mar.  ISSl. 

This  work  is  not  only  well  adapted  for  use  as  a 
textbook  In  medical  colleges,  but  is  also  one  of  the 
best  that  a  practitioner  can  have  for  convenient  re- 


ference and  instruction  in  his  library.  As  a  rule, 
such  volumes  are  too  technicil  and  abstruse  for 
study  without  some  didactic  aid,  but  the  volume 
presented  is  easy  of  comprehension,  and  will  be  of 
great  value  to  college  studonts  and  busy  pr.)ctition- 
era.—A.  Y.  Am.  Med.  Bi-Wetkly,  April  9,  1881. 

The  tables  particuliirly  demand  praise,  for  tbey 
are  admirably  formed,  both  for  convenience  of  re- 
ference and  fulness  of  information.  In  short,  we 
do  not  remember  to  have  met  with  a  book  which 
could  better  serve  the  student  as  a  guide  to  the  sys- 
tematic study  of  inorganic  chemistry. — LouisvilU 
Med.  News,  March  12,  1881. 


KNAPP'S  TECHNOLOGY;  or  Chemistry  Applied  to 

the  Arts  and  to  Manufactures,     With  American 
additions  by  Prof.  Walter  R.  Jobs.son.     in  two 


very  handsome  octavo  volamee,  with  500  wood 
engravings, cloth,  ^6  00. 


Henry  C.  Lea's  Son  &  Co.'s  Publications— (PAar.,  Mat.  3Ied.,  etc.).    1 1 
JJOFFMAiV  [FRED.),  Ph.D.  and,  jpo  WEE  [FRED.  B.),  Ph.D., 

Prof,  of  Anal.  Chum,  i-n  Phil.  Coll.  of  Pho.rmaey. 

MANUAL  OF  CHEMICAL  ANALYSIS,  as  Applied  to  the  Exami- 

nation  of  Medical  Chemicals  and  their  Preparations.  Being  a  Guide  for  the  Determi- 
nation of  their  Identity  and  Quality,  and  for  the  Detection  of  Impurities  and  Adultera- 
tions. For  the  Use  of  Pharmacists,  Physicians,  Druggists  and  Manufacturing  Chemists, 
and  Pharmaceutical  and  Medical  Studetts.  Third  edition,  entirely  rewritten  and  much 
enlarged.     In  one  very  handsome  octavo  volume,  fully  illustrated.      {Preparing.) 

pARRISH  {ED  WARD), 

Late  Professor  of  MaXeria  Medica  in  the  Philadelphia  College  of  Pharmacy . 

A  TREATISE  ON  PHARMACY.    Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With  many  Formulae  anil 
Prescriptions.  Fourth  Edition,  thoroughly  revised,  by  Thomas  S.  Wn=:&AND.  In  one 
handsome  octavo  volume  of  977  pages,  with  280  illustrations;  cloth.  $5  50  ;  leather,  $6  50; 
half  Russia,  $7 

Of  Or.  Parrish's  great  ■work  onphavmacyit  only  Usher.  I  twill  convey  so  me  idea  of  the  libera  lityivhicli 

remains  to  be  .--aid  that  the  editor  has  dccornplished  has  been  bestowed  upon  its  production  when  we  meL- 

his  work  so  well  as  to  maintain,  in  this  fourth  edi-  cionthat  there  are  no  less  than  2S0  carefully  executed 

tion,  the  high  standard  of  excellence  which  it  bad  Illustrations.  In  conclusion,  we  heartily  recommeud 

attained  in  p  re  viou.^.^  editions,  under  the  editorship  of  the  work,  not  only  to  pharmacists,  but  also  to  the 

its  accomplished  author.     This  has  not  been  accom-  multitude  of  medical  practitioners  who  are  obliged 

plished  without  much  labor, and  many  additions  and  to  compound  their  own  medicines.    It  will  ever  h^'ld 

improvements,  involving  changes  in  the  arrange-  an  honored  place  on  our  own  bookshelves. — Dublin 

mentof  the  several  parts  of  the  work,  and  the  addi-  Med.  Press  and  Circular,  Aug.  12,  1S74. 

tioa  of  much  new  matter.     With  the  modifications        Po,.>,cr,c /^no  if  „«►*>,=  „,...=.»  ;..„„,-.,    ,v      i 

I'ernaps  one,  ii  not  the  most  important  book  upon 

pharmacy  which  has  appeared  in  the  English  lan- 


thas  effected  it  constitutes,  as  now  presented,  a  com- 
pendium of  the  science  and  artindi.-pensable  to  the 
pharmacist,    and  of    the    utmost   value    to    everv 

practitioner   of  medicine  desirous  of  fainiliarizing    side^^VIhe  w^t^rTnd  tre°fa"ctshows"us  tYatVrealiy 
himself  with  the  pharmaceutical  preparation  of  the    nsefnl  work  nev^rbor-omo^  m»rpl^  in.ci  ;  n  u=  f,  '  / 


guage  has  emanated  from  the  transatlantic  press. 
"Parrish's  Pharmacy'- is  a  well-known  work  on  this 


articles  which  he  prescribes  for  his  patieuts. 
eago  Hed.  tTotirn.,  July,  1S74. 


-Chi- 


useful  work  ueverbecomes  merely  local  in  its  fame. 
Thanks  to  the  judicious  editing  of  Mr.  Wiegand,  the 
posthumous  edition  of  "Parrish"  has  been  saved  to 


The  work  is  eminently  praotical,  and  has  the  rare    the  public  with  all  the  mature  experience  of  its  an- 
merit  of  being  readable  and  interesting,  while  it  pre-    thor.  and  perhaps  none  the  worse  for  a  dash  of  neTr 
serves  astrictly  sciemificcharacter-  The  whole  work    blood. — Lond.  Pharrn.  Journal,  Oct.  17, 1874. 
reflects  the  greatest  credit  on  author,  editor,  and  pub- , 


QRIFFITH  (ROBERT  E.),  M.D. 

A  UNIVERSAL  FORMULARY,  Containing  the  Methods  of  Prepar- 
ing and  Administering  Officinal  and  other  Medicines.  The  whole  adapted  to  Physiciars  and 
Pharmaceutists.  Third  edition,  thoroughly  revised,  with  numerous  additions,  Idt  Jons  M. 
Maisch,  Professor  of  Materia  Medieain  the  Philadelphia  College  of  Pharmacy.  In  one  large 
and  handsome  octavo  volume  of  abrut  800  pages.     Cloth,  $4  50  ;  leather,  %b  50. 
A  more  complete  formulary  than  itis  in  its  pres      mitted   to   memory  by  every  student  of  medicine 
ent  form  the  pharmacist  or  physician  could  hardly  '  As  a  help  to  phy.sicians  it  will  be  found  inv«lniible, 
desire      To  the  first  some  such  work  is  indispen-a     and  doubtless  will  make  its  way  into  libraries  no- 
ble, and  it  is  hardly  less  essential  to  the  practitionei    already  supplied  with  a  standard  work  of  the  kind, 
who  compounds  his  own  medicines.     Much  of  what    — The  American  Practitioner  ,Loms-<;iUe,  July, "!4. 
is  eoataiaed  in  the  introduction  ought  to  be  com-  i 


F 


^ARQUHARSON  [ROBERT),  M.D. , 

Ler^turer  on  Materia  Medica  at  St.  Mary's  Hospital  Medical  School. 

A  GUIDE  TO  THERAPEUTICS  AND  MATERIA  MEDICA. 


Se- 


eond  American  edition,  revised  by  the 
Pharmacopoeia.  By  Frank  Woodbuet 
pages:  cloth,  $2.25.     {Lately  Issued.) 

The  appearance  of  a  new  edition  of  this  conve- 
nient and  handy  book  in  less  than  two  years  may 
certainly  be  taken  as  an  indication  of  its  useful- 
ness. Its  convenient  arrangement,  and  its  terse- 
ness, and,  at  the  same  time,  completeness  of  the 
information  given,  make  it  a  handy  book  of  refer- 
ence.— Am.  Journ   of  Pharrna.cy,  June.  1S79. 

This  work  contains  in  moderate  compass  such 
well-dieested  facts  concerning  the  pbysiologTcal 
and  therapeutical  action  of  reiredies  as  are  reason- 
ably established  up  to  the  present  time.  By  a  con- 
venient arrangement  the  correspondire  effects  of 
each  article  in  health  and  disease  are  presented  in 
parallel  columns,  not  only  rendering  reference 
easier  but  also  impressing  the  facts  more  strongly 
nrion  the  mind  of  the  reader.  The  book  has  been 
adapted  to  the  wants  of  the  American  student,  and 


Author.     Enlarged  and  adapted  to  the  U.  S. 
,  M.D.     In  one  neat  royal  12mo.  volume  of  498 

copious  notes  have  beenintrodnced,  embodying  the 
latesf  revision  of  the  Pharmacopceia,  together  wi  h 
the  antidotes  to  the  more  prominent  poisons,  and 
Buchofthe  newer  remedial  a  sen  ts  as  ."eemed  neces- 
sary ro  the  completeness  of  the  work.  Tables  of 
weights  and  measures,  and  a  good  alphabetical  in- 
dex end  the  volume. — Druggists''  Circular  and 
Chemical  Qazette.  June,  1879. 
!  It  is  a  pleasure  to  think  that  the  rapidity  with 
which  a  second  edition  is  demanded  may  be  taken 
as  an  indication  that  the  sense  of  appreciation  of  the 
value  of  reliable  information  reearding  the  use  of 
remedies  i-  not  entirely  overwhelmed  in  the  cultiva- 
tion of  pathologicalstudies,  ebaracreristicof  the  pre- 
sent day.  This  work  certainly  merits  the  success  it 
has  so  quickly  achieved. — New  Remedies,  July,  '79. 


CHRISTISOX'SDISPEN'SATORT.  With  copiousad- 
ditions.  and  213  large  wood  engravings  By  R 
E'*LESFiEi.D  Griffith,  II. D.  One  vol.  Svo.,  pp. 
1000  cloth, *4  00. 


;aEPEXTEK'6  prize  ESSAY  ON  THE  USE  OF 
Alcoholic  LiQroKS  in  Health  and  Disease.  JJew 
edition,  with  a  Preface  by  D.  F.  Coxdie.  M  D.,  and 
explanations  of  scientifirwords.  In  oneneatl  2inOi 
volume,  pp.  17S,  cloth,  60  cents. 


12  Henry  C.  Lea's  Son  &  Co.'s  Publications — (^Mat.  Med.  and  Therap.). 
fJTJLLE  {ALFRED),  M.D.,  LL.D.,  and  JlfAJSCH  (JOHN  M.),  Ph.D., 

f^        Prof  .of  Theory  'ind  Practic  of  Medicine  -^'-*-        Prof.ofMnt.MeA.andBot.inPhila. 

and  of  Clinical  Med.  in  Univ.  of  Pa.  Coll.  Phnrmncy,  Secy,  to  the  American 

Pharmace^tiical  AD-fociation. 

THE   NATIONAL  DISPENSATORY:  Contaiuinjr  the  Natural  History, 

Chemistry,  Pharmacy,  ActionF  and  Uses  of  Medicines,  includin<^  those  recognized  in 
the  Pharmacopoeias  of  the  United  St^ites,  Great  Britain  and  Germany,  with  numer- 
ous references  to  the  French  Codex.  Second  edition,  thoroutrhly  revised,  with  numerous 
additions.  In  one  very  handsome  octavo  volume  of  1692  paEces.wlth  239  illustrations. 
Extra  cloth,  $6  75;  leather,  raised  bands,  $7  50;  half  Russia,  raised  bands  and  open 
back,  $8  25.     {Now  Ready.) 

Preface  to  the  Second  Edition. 

The  demand  which  has  exhausted  in  a  few  months  an  unusually  large  edition  of  the  National 
Dispensatory  is  doubly  gratifying  to  the  authors,  as  showing  that  tley  were  correct  in  thinking 
that  the  want  of  such  a  work  was  felt  by  the  medical  and  pharmaceutical  professions,  and  that 
their  efforts  to  supply  that  want  have  been  acceptable.  This  appreciation  of  their  labors  has 
stimulated  them  in  the  revision  to  render  the  volume  more  worthy  of  the  very  marked  faTor 
■with  which  it  has  been  received.  The  first  edition  of  a  work  of  i=uch  magnitude  must  necessarily 
be  more  or  less  imperfect;  and  though  but  little  that  is  new  and  important  has  been  brought 
to  light  in  the  short  interval  since  its  publication,  yet  the  length  of  time  during  which  it  was 
passing  through  the  press  rendered  the  earlier  portions  more  in  arrears  than  the  la-er.  The 
opportunity  for  a  revision  has  enabled  the  authors  to  scrutinize  the  work  as  a  whole,  and  to 
introduce  alterations  and  additions  wherever  there  has  seemed  to  be  occasion  for  improve- 
ment or  greater  completeness.  The  principal  changes  to  be  noted  are  the  introduction  of  seve- 
ral drufs  under  separate  headings,  and  of  a  large  number  of  drugs,  chemicals  ^nd  pharma- 
ceutical preparations  classified  as  allied  drugs  and  preparations  under  the  heading  of  more 
important  or  better  known  articles  :  these  additions  comprise  in  part  nearly  the  entire  German 
Pharmacopoeia  and  numerous  articles  from  the  French  Codex.  All  new  investigations  which 
came  to  the  authors"  notice  up  to  the  time  of  public.Ttion  have  received  due  consideration. 

The  series  of  illustrations  has  undergone  a  corresponding  thorough  revision.  A  number  have 
been  added,  and  still  more  have  been  substituted  for  such  as  were  deemed  less  satisfactory. 

The  new  matter  embraced  in  the  text  is  equal  to  nearly  one  hmdred  pages  of  the  first  edition. 
Considerable  as  are  these  changes  as  a  whole,  they  have  been  accommodated  by  an  enlargement 
of  the  page  without  increasing  unduly  the  size  of  the  volume. 

While  numerous  additions  have  been  made  to  the  sections  which  relate  to  the  physiological 
action  of  medicines  and  their  use  in  the  treatment  of  disea=e,  great  care  has  been  taken  to 
make  them  as  concise  as  was  possible  without  rendering  them  incomplete  or  obscure.  The 
doses  have  been  expressed  in  the  terms  both  of  troy  weight  and  of  the  metrical  system,  for  the 
purpose  of  making  those  who  employ  the  Dispensatory  familiar  with  the  latter,  and  paving  the 
way  for  its  introduction  into  general  use. 

The  Therapeutical  Index  has  been  extended  by  about  2250  new  references,  making  the  total 
number  in  the  present  edition  about  6000. 

The  articles  there  enumerated  as  remedies  for  particular  diseases  are  not  only  those  which, 
in  the  authors'  opinion,  are  curative,  or  even  beneficial,  but  those  also  which  have  at  any  time 
been  employed  on  the  ground  of  popular  belief  or  professional  authority.  It  is  often  of  as 
much  consequence  to  be  acquainted  with  the  worthlessness  of  certain  medicines  or  with  the 
narrow  limits  of  their  power,  as  to  know  the  well  attested  virtues  of  others  and  the  conditions 
under  which  they  are  displayed.  An  additional  value  posse.-sed  by  such  an  Index  is,  that  it 
contains  the  elements  of  a  natural  classification  of  medicines,  founded  upon  an  analysis  of  the 
results  of  experience,  which  is  the  only  safe  guide  in  the  treatment  of  disease. 

This  evidence  of  success,  seldom  paralleled,  keep  the  work  up  to  the  time. — ^Vew  fier/iedie*,  Not. 
shows  clearly  how  well  the  authors  have  met  the    1S79. 

existing  needs  of  the  pharmaeeutical  and  medical  ^i,,-,  j^  ^  ^^^^  ^o^^  t^^  t^o  of  the  ab]e.et  writer?  on 
professions.  Gr.itifying  as  it  must  be  to  them,  they  materia  me.lica  in  America  The  authors  have  pro- 
have  embraced  the  opportunity  offered  for  a  thor-  ^^^^.^  ^  work  which,  for  accuracy  and  comprt-hensive- 
ongh  revision  of  the  whole  work,  striving  to  em-  ness,  is  unsurpas-^ed  bv  any  work  on  the  subject.  There 
brace  within  it  all  that  might  have  been  omitted  in  j^  ^^  ^ook  in  the  EnzUsh  laneuatre  \<hich  contains  ?o 
the  former  edition,  and  all  that  has  newly  appeared  much  valuable  information  on  the  various  articles  of 
of  sufficient  importance  daring  the  time  of  its  col-  ^^^  materia  medica.  The  work  has  cost  the  authors 
laboration,  and  the  short  interval  elapsed  since  the  years  of  laborious  study,  but  they  have  succeeded  in 
previous  publication.  After  hiving  gone  carefully  producing  a  dispensatory  which  is  not  only  national, 
through  the  volume  we  mnst  admit  that  the  authors  but  will  be  a  lasting  memorial  of  the  learning  and 
have  labored  faithfully,  and  with  success,  in  main-  abilitv  of  the  authors  who  produced  it.— Edinburgh 
taininz  the  high  character  of  their  work  as  a  com-    ifdicaljournal,  Nov.  1879. 

peudium  meeting  the  reqtiirements  of  the  day   to  international  or  universal  than 

which  one  can  safely  turn  in  quest  of  the  latest  lo-  .t'     v     i       <•  «v     i  •    j  •  i  j 

^rmation  concerning  evervthing  worthy  of  notice  in  i  ^ny  other  book   of  the  kmd  in  our  language,  and 

connection  with  Pharmacy,   Materia   Medica,   and  1 '"''jJV''"^?"'"''^?  t'.T^ ''"''•  "^ 

Therapeutic6.-47n.  Jour,  of  Pharmacy,  Nov.' 1879.    ^^'^  ^^rfr.  -Journ.,  Oct.  IS,  9. 

-^  .       .^,  .  _,   „„ ,u„»„„„ „„„„»„  .^„,        The  National  Dispensatory  is  beyond  dispute  the 

It  IS  with  great  pleasure  that  we  announce  to  our  °      .        ,      .._*^    .^  .,  '.,_ i^„f  „„„%^i„,„  ;„ 

readers  the  appearance  of  a  second  edition  of  the    ^f/y  best  authority     It  is  thronghoat  comp  ete  in 

National  Dispensatorv.    The  total  exhaas.ion  of  the  \  »  1  '^^.  necessary  ^T^^^j}^''JJJtLll    t^^.TJ^^ 

first  edition  i'n  the  sliort  space  of  six  months,  is  a  |  ^-]^^:c,^  '2lltT:^,^'.l'':^:Z:'J^LT^l 

Eufficier 

work 

sale 

;^^^mJiri=a^y^^^th^b^  :  — ^^--^^^^^^P^r^^^Ll^g^^^ia^ 

and  improved,  which  proves  that  the  authors  do  not    Canada  Med.  and  Surg.  Journ.,  Feb.  ISSO. 
intend  to  let  the  grass  grow  under  their  fbet,  but  to  ' 


Henry  C.  Lea's  Son  &  Co.'s  Publications — ( Mat.  Med.,Therap.,  etc.).   13 
JJTAJSCR  {^JOHN  M.),  Phar.  D.,  ~ 

Frnf.  of  ilat'Tta  M^dica  anrl  Bnfnny  in  thf  Phi'ir.  Cr-V.  rf  Phnrman/. 

A  MANUAL  OF  ORGANIC  MATERIA  MEDICA.     Being  n  Guide 

to  Materia  Medica  of  the  Vegetable  and  Animal  Kingdoms.  For  the  use  of  Students, 
Druggists,  Pharmacists  and  Physicinns.  In  one  handsome  12mo.  volume,  with  numer- 
ous illustrations  on  wood.      (Preparing.) 

EXTRACT  PROM  THE  AUTHOr's  PREFACE. 

When  in  1866  the  author  wa.«  called  to  the  chair  of  Materia  Medica  in  the  institution  named 
(the  Philadelphia  College  of  Pharmacy),  he  seriously  felt  the  need  of  a  puitahle  text  bf^ok 
which  could  be  used  in  connection  with  his  lectures,  and  made  preparations  for  the  publication 
of  such  a  work  at  an  early  date.  To  elaborate  a  .'ystem  of  classification,  which  should  be  with- 
out difficulty  comprehended  and  rendily  applied  by  those  for  whom  it  was  intended,  was  by  no 
means  an  easy  task,  and  the  author  found  occnsion,  almost  everj'  year,  to  either  remodel  that 
previously  selected,  or  to  make  whit  in  his  opinion  seemed  to  be  desirable  improvements.  The 
publication  of  the  "  National  Dispensatory"  in  a  measure  supplied  the  want  felt,  at  least  ns  far 
as  a  work  of  reference  is  cou'-erred,  but  owing  to  its  local  arrangement,  it  is  not  adapted  to 
systematic  instruction.  However,  its  publication  rendered  a  modification  of  the  original  plan 
for  a  treatise  on  Materia  Medica  desirnble,  and  it  is  now  presented  in  a  form  giving  an  outane 
of  the  substance  of  the  lectures  and  embracing  what  are  considered  the  essential  phj'sical,  histo- 
logical, and  chemical  characters  of  the  organic  drug,  so  as  to  render  the  work  also  a  useful  and 
reliable  guide  in  business  transactions.  Regnrding  the  classificntion,  the  author  is  conscious 
of  its  imperfections,  but  he  believes  it  to  be  convenient  and  capable  of  practical  application. 

In  reference  to  the  scope  of  the  work,  the  main  aim  has  been  to  embrace  all  the  drugs  recog- 
nized by  the  U.  S.  Pharmacopcei.n,  together  with  the  old,  but  now  unofficinal  ones,  and  such 
others,  the  use  of  which  has  been  recently  revived  or  suggested,  and  which  seem  to  deserve 
attention.  The  medical  properti'^'S  nnd  doses  of  the  various  drugs  are  merely  briefly  stated  as 
subjects  of  general  important  information  ;  the  present  work  is  not  intended  for  giving  instruc- 
tion in  the  therapeutic  application  of  drugs. 


^TILLE  [ALFRED],  M.D., 

Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna . 

THERAPEUTICS  AND  MATERIA  MEDICA ;  a  Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History. 
Fourth  edition,  revised  and  enlarged.  In  two  large  and  handsome  8vo.  vols,  of  about  20U9 
pages.     Cloth,  §10;  leather,  $12;  half  Russia,  $1.3. 

of  the  present  edition,  a  whole  cyclopsedia  of  thera- 
peutics.— Chicago  2Iedical  Journol^'E&h.  1S75. 

The  rapid  exhaustion  ofthree  editions  and  the  nni- 
vei'sal  favor  with  which  the  work  has  been  received 
by  the  medical  profession,  are  sufficient  proof  of  its 
excellence  as  a  repertory  of  practical  and  useful  in- 
formation for  the  phy.sician.    The  edition  before  us 


It  is  unnecessary  to  do  mucli  more  than  to  an- 
nounce the  appearance  of  the  fourth  edition  of  this 
well  known  and  excelleat  work. — Brit,  and  For. 
Med. -Chir.  Review,  Oct  1575. 

For  all  who  desire  a  complete  work  on  therapeu- 
tics and  materia  medica  for  reference,  in  cases  in- 
volving medico-legal  questions,  as  well  as  for  in- 
formation concerning  remedial  agents.  Dr.  Still6'sis'  fully  sustains  this  verdict,  as  the  work  has  been  car  e- 
"■par  uxoellenee"  the  work.  Beingout  of  print, by  :  fully  revi.sed  and  in  some  portions  rewritten,  briug- 
the  exhaustion  offormer  editions,  the  author  has  laid  :  ing  it  up  to  the  present  time  hj  the  admission  of 
the  profession  under  renewed  obligations,  by  the  I  chloral  and  croton-chloral.  nitrite  of  arnyl,  bichlo- 
careful  revision,  importantadditions,  and  timely  re- ;  ride  of  methylene,  methylie  ether,  lithium  com- 
issuing  a  work  not  exactly  supplemented  by  any  j  pounds,  gelserainum,  and  other  remedies. — Am.. 
other  in  the  English  language,  if  in  any  language.  |  .Xo^irn.  of  Pharmacy,  Feb.  1S7.5. 
The  mechanical  execution  handsomely  sustains  the  we  can  hardly  admit  that  it  lj.as  a  rival  in  the 
well-known  skill  and  good  taste  of  the  publisher.— |  niultitode  of  its  citations  aad  the  fulness  of  its  re- 
Si.  Louis  Med.  and  Surg.  Journal,  Dec.  1874.  j  gearch  into  clinical  histories,  and  we  must  assign  it 

From  the  publication  of  the  first  edition  "Stille's  !  a  place  iu  the  physician's  library  ;  not,  indeed,  as 
Therapeutics"  has  been  one  of  the  classics;  its  ah- i  fully  representing  the  present  state  of  knowledge  in 
sence  from  our  libraries  would  create  a  vacuum  i  pharmacodynamics,  but  asbyfarthe  mo«t  complete 
which  could  be  filled  by  no  other  work  in  the  Ian-  treatise  upon  the  clinical  and  practical  side  of  the 
guage,  audits  presence  supplies,  in  the  two  volumes:  question. — Boston  Med.  and  Surg.  Jou-rnal, ^soy  .  5,. 

1  1S74. 


fiORNIL  (F.),  AND 

^        Prof,  in  the  Faculty  of  Med.,  r'aris 


f>ANVIER  [L.], 

J-ii        Prof  inthe  O'lllegeof  Fi-amee. 

MANUAL  OF  PATHOLOGICAL  HISTOLOGY.     Tmn slated,  with 

Notes  and  Additions,  by  E.  0.  Shakespeare,  M.D.,  Pathologist  and  Ophthalmic  Surgeon 
to  Philada.  Hospital,  Lecturer  on  Refrpction  and  Operative  Ophthiillnic  Surgery  in  Univ. 
of  Penna.,  and  by  Henry  C.  Simes.  M  D.,  Demonstratrr  of  Pathological  Histology  in 
the  Univ.  of  Pa.  In  one  very  handsome  octavo  volume  of  over  700  pages,  with  over 
350  illustrations.     Cloth,  S6  50;  leather,  $6  50  ;   half  Russia,  %T,     (Jhtst  Ready.) 


We  have  no  hesitation  in  cordially  recommending 
the  Eaglish  translation  ofCornil  &  Ranvier's  -'Pa- 
thological Histology"  as  the  best  work  of  the  kind 
in  any  language,  and  as  giving  to  its  readers  a 
trustworthy  guide  in  obtainiog  a  broad  and  solid 
i^asis  for  the  appreciation  of  the  practical  bearings 
of  pathological  anatomy. — A'ln.  Journ.  of  Med. 
Sciences,  Aoril,  1880. 

This  important  work,  in  its  American  dress,  is  a 
welcome  offering  to  all  students  of  the  subjects 
which  it  treats.  The  great  mass  of  material  is 
arringed  naturally  and  comprehensively.  The 
clj-ssifieation  of  tumors  is  clear  and  full,  so  far  as 


the  subject  idmits  of  definition,  and  this  one  chap- 
ter is  worth  the  price  of  the  book.  The  illustra- 
tions are  copious  and  well  chosen.  "Without  the 
slightest  hesitation,  the  translators  deserve  honest 
thanks  for  placing  this  indispensable  work  in  the 
hands  of  American  students. — Phila.  Med.  Times, 
April  24,  18^0 

This  volume  we  cordially  eommead  to  theprofes- 
sion.  It  will  prove  a  valuable,  almost  necessary, 
addition  to  the  libraries  of  j-tudents  who  are  to  he 
physicians,  a  ad  to  the  libraries  of  staden's  who  are 
physicians.— ulrnerican  Praeiiifianer,  Jnne,  18S0. 


14       Henry  C.  Lea's  Son  &  Co.'s  Publications — {Pathology^  etc.). 


PENWICK  {SAMUEL),  M.D., 

-*■  Ansistant  Phi/.iici'in  to  the.  Londnn  ffnxpital. 

THE  STUDENT'S  GUIDE  TO  MEDICAL  DIAGNOSIS. 


From  the 

Third  Revised  and  Enlarged  English  Edition.     With  eighty-four  illnstrations  on  wood. 
In  one  very  handsome  volnme,  royal  12mo. ,  cloth,  $2  25.      (Lately  Issued.) 

flREEN  [T.  HENRY), M.D., 

^-*  Kecturer  on  Pnlholngy  and  MnrhUI  Anatomy  nt  Chnring-CroxD  Hospital  Medical  School,  etc. 

PATHOLOGY  AND  MORBID  ANATOMY.  Fourth  American, from 

the  Fifth  Enl.arged  and  Revised  English  Edition.     In  one  very  h.indsome  octavo  Tolnme 
of  about  350  pages,  with  1.38  fine  engravings;   cloth,  $2  25.     (Just  Ready.) 
Extract  from  the  Author'.s  Preface. 
In  preparing  the  fifth  edition  of  ray  Te.xt-bnnk  on   Pathology  and  Morbid  Anatomy,  I  have 
ag.iin  added  much  new  matter,  with  the  object  of  making  the  work  a  more  complete  guide  for 
the  student.     All  the  chiipter.«  have  been  carefully  revised,  some  :ilteration,s  b.ave  been  made  in 
the  arrangement  of  the  work,  and  an  addition  has  been  made  to  the  number  of  wood-cuts.     The 
new  wood  cuts,  as  in  previous  editions,  have  been  drawn  by  M.-.  CoUings  from  my  own  micro- 
scopical preparations. 

We  have  long  considered  this  the  best  guide  yet  bnon  thorouebly  revised,  and  mnch  new  raatier 
p-esentei  to  the  student  for  the  identification  of  va-  has  been  ?dded.  To  the  physician  as  a  guide  in 
rions  morbid  tissues.  We  have  found  it  more  satis-  diagnosis,  we  recoininend  this  volnme. — Phy.tioian 
factory  than  any  other.     The  present  edition   has     and  Surgeon,  May,  ISSl. 

DRISTOWE  [JOHN  SYER),  M.D.,  F.R.C.P., 

JL?  Phynician  and  .Toint  Lecturer  on  Medicine ,  St    T^omax's  Hnxpital. 

A    TREATISE    ON    THE    PRACTICE    OF    MEDICINE.     Second 

American  edition,  revised  by  the  Author.  Edited,  with  Additions,  by  James  H.  IIutch- 
issoN,  M  .D.,  Physician   to  the   Penna.  Hospital.     In  one   handsome  octavo  volume  of 
nearly  1200  pnges.      With  illustrations.     Cloth,  $5  00  j    leather,  $6  00;  half  Russia, 
$6  60.      {Kow  Ready.) 
The  second  edition  of  tliis  excellent  work,  like  the  |      The  views  of  the  author  are  expressed  with  preci- 

first,  has  received    the  benefit  of  Dr.   Hutchinson's  !  sion  and  sufficient  promptness  to  impress  the  sindeut 

aunotHtions,  by  which  the  phases  of  disease  which     with  the  weight  of  his  authority;  and  should  the 

are  peculiar  to  this  country  are  indicated,  and  thus     medical  professor  differ  c)u  any  subject  from  his  doc- 

a    treatise   which  was  intended  for   British   practi-    trine,  he  will  need  to  find  strong  arguments  to  carry 

tioners  and  students  is  made  more  practically  nst:fnl 

on    this   side  of  tbe  water.     We   see    no   reason   to 

modify  the  high  opinion  previously  expressed  with 

regard    to    Dr.   Bristowe's  \Tork,  except    by  ad<iing 

our  appreciation  of  the  careful  lab  rs  of  the  author 

in  following  the  lateral  giowth  of  medical  science. 

—  ^oxton  Medical  and  Surgical  Journal,  February, 

ISSO 
What  we  said  of  the  first  edition,  we  can,  with 

increased  emphasis,  repeat  concerning  this:  "Every 

patre  is  characterized  by  the  n iterance"  of  a  thought 

fnl  man 


his  class  to  the-'pposite  conclusion. — N.  0.  Med.  and 
Surg.  Jnnrn  ,  Feb.  18,'0. 

The  reader  will  find  every  conceivable  snbieot 
connected  with  the  practice  of  medicine  ably  pre- 
sented, in  a  styl"  at  once  clear,  interestiDg,  and  con- 
cise. The  additions  mvde  by  Dr.  Hntchinsou  are 
appropriate  and  practical,  and  greatly  add  to  its 
usefulness  lo  .American  readers. — Buffalo  Med.  and 
Surg.  Journ.,  March,  18S0. 

We  regaidit  as  an  excellent  work  for  students  and 
for  practitioners.    It  is  clearly  writtei,  the  author's 


il  man.     What  has  been  said,  has  been  well  said,  i  ,.(yig  j,  attractive,  and  it  is  especially  to  be  cona- 
nd  the  book  is  a  fair  reflex  of  all  that  is  certainly  I  mended  for  its  excellent  expositiou  of  the  pathol,gy 


■'wn  on   the  subjects  considered." — Ohio   Med 
Recorder,  Jan.  7, 1S80, 


and  clinical  phenomena  of  disease. — St.  Louis  Clin. 
Record,  Feb.  ISSO. 


B 


'ABERSnON  [S.  O.)  M.D. 

Senior  Physician  to,  and  Late  Lecturer  on  the  Principles  and  Practice  of  Medicine  at,  Guy'» 
Hospital,  etc. 

ON  THE  DISEASES  OF  THE  ABDOMEN,  COMPRISING  THOSE 

of  the  Stomach,  and  other  parts  of  the  Alimentary  Canal,  (Esophagus,  Caecum,  Intes- 
tines and  Peritoneum.  Second  American,  from  the  Third  enlarged  and  revised  Eng- 
lish edition.  With  illustrations.  In  one  handsome  octavo  volume  of  over  600  pages. 
Cloth,  $3  50.  {Late/y  Issued.) 
=  valuable  treatise  on  diseases  of  thf  stomach  I  amended  by  the  author.  Several  new  chapters  have 
bdomen  has  been  ont  of  print  for  several  years,     been  added,  bringing  the  work  fully  up  to  tbe  times, 

and  making  it  a  volnme  of  interest  to  the  practi- 
tioner in  ev^ry  field  of  medicine  and  surgery.  Per- 
verted nnfritiou  is  in  some  form  associated  with  all 
di.-iemes  we  have  to  combat,  and  we  need  all  the 
light  that  c*n  he  obtained  on  a  subject  so  broad  and 
general.  Dr  Hahershon's  work  is  one  that  every 
practitioner  sh  mid  read  and  study  for  himself. — 
iV.  r.  Med.  Journ  ,  April,  1879. 


Thi 

.and  a 
and  is  therefore  not  so  well  known  to  the  profe 
a-i  it  deserves  to  be.  It  will  be  found  a  cycloi)sedia 
of  information,  systematically  ^rran«ed,  on  all  dis- 
eases of  the  alimentary  tract,  from  the  mo  ith  to  the 
rectum  A  fair  proportion  of  each  chapter  is  devoted 
to  symptoms,  pathology,  and  therapeutics.  The 
present  edition  is  fuller  than  form."r  ones  in  many 

I  particulars,  and  has  been  thoroughly  revised   and 


GLUGE'S  ATLAS  op  PATHOLOGICAL  HISTOLOGY.  . 

Translated,  with  Notes  and  Additions,  by  Jo.seph 

Leidt,  M.  D.    In  onevolume,  very  large  imperial 

quarto,  with  320  copper-plate  figures,  plain  and 

colored, cloth.    $4  00 
LA  ROCHE  ON  YELLOW  FEVER, considered  in  Its' 

Historical,  Pathological,    Etiological  and  Thera 

peiitical  Relations.     In  two  large  and  handsome! 

ortsTo  rolnmPB  of  nearly  I.'iOO  pp  .cloth      $7  00. j 

STOKES'  LECTORES  ON  FEVER      Edited  by  Johk  ,  tODD'SCLINICAL  LECTDRE?  osCERTAIN  ACU7  B 
Wn.i.iAM  MooRK,  M.  0..  Assistant  Physician  to  the  j      DtssA.^E.s     In  one  neatootavo  volnme,  of  320  pp. 
C  'rk   Street   Fever   Hospital,    In   one   neat  8vo         cloth     $2  50 
▼olume  cloth.  $2  00.  I 


PAVY'S  TREATISE  ON  THE  FUNCTION  OF  DI- 
GESTION: its  Disorders  and  their  Treatment. 
From  the  Second  London  edition.  In  one  hand- 
some volume,  small  octavo,  cloth,  ^2  00. 

HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIOXS.     1  vol.  8vo.,  pp.  •'iOO,  cloth.    *.'?  -"iO 

BARLOW'S  MAN0AL  OF  THE  PRACTICE  OP 
MEDICINE.  With  Additions  by  D.  F.  Coj»bib, 
M    D.     1  vol.  8vo.,  pp.600,  cloth.     *5  .50. 


Henry  C,  Lea's  Son  &  Co.'s  Publications— (Practice  of  Medicine).  15 


fjfLINT  {A  USTIN),  M.D., 

•^  Profpssornf  the  Principles  and  Practiee.  of  Mf:d/(.<nneinBeVUw.e  Med  College  N  Y. 

A   TREATISE    ON   THE    PRINCIPLES  AND    PRACTICE    OF 

MEDICINE  ;  designed  for  the  use  of  Students  and  Practitioners  of  Medicine.  Fifth 
edition,  entirely  rewritten  and  much  improved.  In  one  large  and  closely  printed  octavo 
volume  of  1153  pp.  Cloth,  $5  60;  leather,  $6  50;  very  handsome  half  Russia,  raised 
hands,  $7.     {Just  Ready.) 

This  work  hasbeenso  long  ind  favorably  known,  j  years  before  it  yields  thn   place  to  others.— iV"ff*'>- 
and  has  obtained  so  high  a  positioa  amongst  mod-  ,  xiille  Journ.  of  Med.  and  Surg  ,  Feb.  1S81. 


ern  treatises  on  medicine,  that  it  is  hardly  neces 


"Flint's  Practice"  is  recognized  to  be  a  standard 


saryto  do  more  than  annoance  the  pubUcation  of  I  t..,,-  ,  V- T  ,,  •<='^^S"'-^'^  )■''  o«  a  sv^uuara 
this  fifth  edition.  All  who  perase  it  mu.t  be  «truck  ^  i"-? 'V^,«  "i  ^'^l  ':*°^  "I"""  the  prmcples  and  the 
by  the  exteosive  research   which  has  been  under-    ^r^^^"'^  «f  medicine  wherever  the  Enf?l,sh  language 


taken  in  the  revision  of  this  edition,  combined  with 
mncb  original  thonght.  There  is  hardly  a  subject 
which  does  not  receive  fresh  illastratiou  and  discus- 
Mon,  openins;  up  new  lines  of  inqnii-y  which  had  not 
been  thonght  of  when  the  previous  edition  appeared. 
We  cannot  ennclU'de  this  notice  without  expressing 
our  admiration  of  this  volume,  which  is  certainly 
one  of  the  standard  text-books  on  medicine,  and  we 


practice  of  medicine  wherever  the  English  language 
is  read.  The  opinions  everywhere  reveal  the  man 
of  extensive  experience,  diUsent  study,  calm  jadg- 
raeat,  and  unbiassed  criticism.  The  work  thnuld 
be  in  the  hands  of  every  practitioner. — New  York 
Med.  Record,  Feb.  26,  ISSl. 

The  style  and  chanicrer  of  this  work  are  too  well 
known  to  the  profession  fo  reqnire  an  introduction. 
For  a  number  of  years  thi«  volume  has  occupied  a 


may  safely  affirm  that,  taken  altogether,  it  exhibits    leading  position  as  a  text-book  in   the  majority  of 


a  fuller  and  wider  acquaintance  with  recent  patho 
logical  inquiry  than  any  similar  work  with  which 
we  are  acquainted,  whilst  at  the  same  time  it  shows 
its  author  to  be  possessed  of  the  rare  faculties  of 
clear  exposition,  thoughtful  discrimination,  and 
sound  judgment. — Lond^oa  Lancet,  July  %i,  ISSl. 

Practically,  this  edition  is  a  new  work;  for  so 
many  additions  and  changes  have  been  made  that 
one  well  acquainted  with  previous  editions  would 


medical  schools,  and  the  high  position  accoriled  to 
it  in  the  past  is  a  guarantee  of  a  hearty  welcome  in 
this  new  edition.  The  book  may  be  said  to  represent 
the  present  state  of  the  science  of  medicine  as  now 
understood  and  taua;ht.  Ills  a  safe  guide  lo  students 
and  practitioners  of  medicine. — Maryland  Medical 
Journal.  March  1,  1881. 

The  author  has,  in  this  edition,  revised  and  re- 
written a  great  oart  and  made  it  accord  with  the 


hardly  recognize  this  as  an  old  friend.  The  size  of  more  advanced  ideas  which  have  been  developed 
the  volumeis  somewhat  increased.  An  entire  new  within  the  past  few  years.  He  is  the  more  fitted  to 
section  and  several  new  chapters  have  been  added.  :  <io  ^o.  a-s  he  is  actively  engaged  in  his  profes-^ion, 
It  is  universally  conceded  that  no  text  book  upon  and  can  make  deducuons,  not  from  the  work  of 
this  subject  was  ever  published  in  this  country  others,  but  from  his  own  labors.  It  is  a  treatise 
that  ca2  at  all  compare  with  it  It  has  long  been  '^hich  every  American  physician  should  hare  upon 
at  the  very  head  of  American  text-book  literature,  ^'^  table,  and  which  he  should  consult  on  occations 
and  there  can  be  ao  do  ubt  bat  that  it  will  be  many    ^^^"^^  bis  leisure  permits  him  to  do  so.— St.  Louis 

I  Med  and  Surg.  Journal,  March,  1881. 

jgr  THE  SAME  AUTHOR. 

CLINICAL  MEDICINE;    a  Systematic  Treatise  on   the  Diagnosis 

and  Treatment  of  Diseases.  Designed  for  Students  and  Practitioners  of  Medicine.  In 
one  large  and  handsome  octavo  volume  of  795  pages;  cloth,  $4  50  ;  leather,  $5  50; 
half  Russia,  $6.     {Now  Ready.) 

in  this  country  as  that  of  the  author  of  two  works 
of  great  merit  on  special  subjects,  and  of  numerous 
papers,  exhibiting  much  originality  and  extensive 
resFarch.  —  The  Dnblin  Journal,  Dec.  1879 

There  is  every  reason  to  believe  that  thi.s  book 
will  be  well  received.  The  active  practitioner  is 
frequently  in  need  of  some  work  that  will  enable 
him  to  obtain  information  in  the  diagnosis  and 
treatment  of  cases  with  comparatively  little  labor. 
Dr.  Flint  has  the  faculty  of  expressing  himself 
clearly,  and  at  the  same  time  so  concisely  as  'o 
enable  the  searcher  to  traverse  the  entire  ground 
of  his  search,  and  at  the  same  time  obtain  all  that 
isessentiil,  without  plodding  through  an  intermi- 
nab'e  space. — N.  Y.  Med.  Jour.,  Nov.  1S79 

The  great  object  is  to  place  before  the  reader  the 
latest  observa-ions  and  experience  in  diagnosis  and 
treat  nent.  Such  a  w  jrk  is  e^^pecially  valuable  to 
students.  I>  is  complete  in  Its  special  design,  and 
yet  80  condensed,  that  he  can  by  its  aid,  keep  up 
with  the  lectures  on  practice  without  neglecting 
other  branches.  It  will  not  escipe  the  notice  of  the 
practitioner  that  such  a  work  is  most  valuable  in 
culling  points  in  diagnosis  and  treatment  in  the  in- 
tervals between  the  daily  rounds  of  visits,  since  he 
can  in  a  few  minutes  refresh  his  memory,  or  learn 
the  litest  advance  in  the  treatment  of  disease*  which 
demand  his  instant  a'tention. — Cincinnati  Lancet 
and  aUnic,  Oct.  25,  1879. 


The  eminent  teacher  who  has  written  the  volume 
ttnder  consileratioo  h.  s  recognized  the  needs  of 
the  American  profession,  and  thf  result  is  all  that 
we  could  wish.  The  style  in  which  it  i-  written  is 
peculiarly  the  author's;  it  is  clear  and  forcible,  and 
marked  by  those  characteristics  which  have  ren- 
dered him  one  of  the  best  writers  and  teachers  this 
country  has  ever  produced.  We  have  not  space  for 
so  full  a  consideration  of  this  remarkable  work  as 
we  would  desire. — St.  Louis  Clin.  Record,  Oct.  1S~9. 

It  is  here  that  the  skill  and  learning  of  the  great 
clinician  are  displayed  He  has  given  us  a  store- 
house of  medical  knowledge,  excellent  for  the  stu- 
dent, convenient  for  the  practitioner,  the  result  of  a 
long  life  of  the  most  faithful  clinical  work,  collect- 
ed by  an  energy  as  vigilant  and  systematic  as  un- 
tiring, and  weighed  by  a  judgment  no  less  clear 
than  his  observation  is  e\.06e.—Archiveg  of  Medi- 
cine, Dec.  1879 

To  give  an  adequate  and  useful  con»pectus  of  the 
extensive  field  of  modern  clinical  medicine  is  a  task 
of  no  ordinary  difficulty;  but  to  accomplish  this 
consistently,  with  brevity  and  clearness,  the  diff^r^nt 
subjects  and  their  several  parts  receiving  the  atten- 
tion which,  relatively  to  tlieir  importance,  medical 
opinion  claims  for  them,  is  still  mo  re  difficult.  Ttjis 
task  we  feel  bound  to  gay  has  been  executed  wi*h 
more  than  partial  success  by  Dr  Flint,  whose  name 
is  already  familiar  to  students  of  advanced  medicine 


DF  THE  SAME  AUTHOR. 

ESSAYS    ON    CONSERVATIVE 


MEDICINE    AND   KINDRED 


TOPICS.     In  one  very  handsome  royal  12rao.  volume.     Cloth,  $1  38,     {Just  Issued.) 
DAVIS'S    CLINICAL     LECTURES     ON    VARIOUS  i  STURGES'S  INTRODUCTION  TO  THE  STUDY  OF 


IMPORTANT  DISEASES;  being  a  collection  of  the 
Clinical  Lectures  delivered  in  the  Medical  Wards 
of  iMercy  Hospi.al,  Chicago.  Edited  by  Frank  H 
Davis,  M.D.  Second  edition,  enlarged.  In  one 
handsome  royal  I2aio.  volume.    Cloth,  $1  75. 


CLINICAL  MEDICINE.  Beinga  Guide  to  the  In 
vestigation  of  Disease.  In  one  handsome  12mo. 
volume,  cloth,  $1  25. 


16    Henry  C.  Lea's  Son  &  Co.'s  PrBLicATiONs — (Practice  of  Medicine). 
pTCHAFDSOX{BEXJ.  W.).  JI.D.,  F.R.S..  M.A.,  LL.D.,  F.S.A., 

-*-^         FeUoW'^/th'-  Royal  college  of  Phytioians,  London. 

PREVENTIVE  MEDICIXE.    In  one  octavo  volume  of  about  500  pages. 

{Shortly.)  

pfARTSHORNE  {HENRY).  M.D., 

•*-*■  Prrifffssor  "f  Hygicntin  fhn  Uniw.rfdttj  of  Pennsylvania 

ESSENTIALS  OF  THE  PRINCIPLES  AND  PRACTICE  OF  MEDI- 
CINE.    A  hanrly  book  for  Students  and  Practitioners      Fifth  edition,   thoroughly  re- 
vised and  rewritten.     With  140  illustrations.     In  one  handsome  royal  12mo.  volume,  of 
about  600  pages.      {In  Press.) 
The  very  great  success  which  has  exhansted  four  large  editions  of  thi.s  work  shows  that  the 
author  has  sucjeeded  in  supplying  a  want  felt  by  a  large  portion  of  the  profession.     It  has  also 
enabled  him  in  successive  revisions  to  perfect  the  details  of  his  plan,  and  to  render  the  work 
still  aiore  worthy  of  the  favor  with  which  it  has  been  received.     In  the  present  edition  several 
hundred  brief  additions  h:ive  been   made,  a  number  of  new  su'-jects  have  been  written  upon, 
especially  in  connection  with  the  Pathology  of  tbe  Nervous  System,  the  illustrations  have  been 
considerably  increased,  and  a  large  number  of  new  and  carefully  selected  formulae  for  the  admi- 
1  istration  of  medicines  have  been  introduced.     An  account  is  given,  also,  in  this  edition  for  th^ 
first  time,  of  the  method  of  prescribing  according  to  the  metrical  system,  and  a  section  is  added 
U;  on  Eyesight,  its  Examination  and  Correction.     In  pre.=enting  this  edition,  therefore,  the  pub- 
lishers feel  that  it  is  in  every  way  worthy  a  continuance  of  the  favor  hitherto  accorded  this  work. 


VrrOODBURY  (FRAiVK).  M.D.. 

''  Phi/sicirrn  to  the  Oermnn  Hrnpital,  PA'7 


fladelphia,  late  Chief  Assist,  to  Med.  Clinic,  Jeff.  College 
Unspitnl,  etc. 

A    HANDBOOK   OF    THE    PRINCIPLES   AND    PRACTICE    OF 

Medicine  ;  for  the  use  of  Students  and  Practitioners.     In  one  neat  volume,  royal  12mo., 
with  illustrations.      {In  Press.) 


JPOTHERGILL  {J.  MILNER),M.D.  Ediv.,  M.R.C.P.  Loud., 

■'-  Asst.  Phyf:.  to  the.  West  Lond   Eogp.  .-  A-i-it.  Phyx.  to  the  City  of  Lond.  Ho.':p..etc. 

THE  PRACTITIONER'S  HANDBOOK  OF  TREATMENT;  Or, the 

Principles  of  Therapeutics.     Second  edition,  revised  and  enlarged.     In  one  very  neat 

octavo  volume  of  about  650  pages.     Cloth,  $4  00;  very  handsome  half  Russia,  $5  60. 

(Just  Ready.) 

The  junior  members  of  the  profession  will  find  in  ,  cated  physician  for  his  efforts  toward  rationalizing 

it  a  work  that  should  not  only  be  read,  but  care-  ,  the  treatment  of  diseases  upon  ihe  scientific  basis 

fully  studied.     It  will  assist    them  in   the  proper  ;  of  physiology.     Every  chapter,  every  line,  has  the 

selectioQ  and  combination  of  therapeutical  agens    impress  of  a  master  band,  and  while  the  work  is 

best  adapted  to  each  case  and  coudition,  and  enable     thoroughly  scientific  in  --very  particular,  it  presents 

them  to  prescribe  iDtelliaently  <ind    ^nccessfolly.     lo  the  thooght.'al  reader  all  the  charms  and  beau- 

To  dfi  fail  justice  to  a  work  of  this  scope  and  chai-    ties  of  a  well-rfritlen  novel.      No   physician    can 

acter  will  be  impossible  in  a  review  o!  this  kind,     well  afford  to  he  without  this  valuable  work,  for  its 

The  b..ok  its-lf  must  be  read  to  be  fully  appreciated      orieiDality  makes  it  fill  a  niche  in  medical  liiera- 

— St.  Louis  Courier  of  Medicine,  Xov   ISSO.  tare   hitherto  vacant. — Nashmlle  Journ.  of  Med. 

The  author  merits  the  thanks  of  every  well-edu-    '*"'*  Surg.,  Oct.  ISSO. 

fpiNLA  YSON  [JAMES),  MJX, 

-*■  Physician  and  Lecturer  on  Clinical  Medicine  in  the  Glasgow  Western  Infirmary,  etc. 

CLINICAL    DIAGNOSIS;    A    Handbook    for    Students   and    Prac- 

titioners  of  Medicine.     In  one  handsome  ^2mo.  volume,  of  546  pages,  with  85  illustra- 
tions.    Cloth,  $2  63.      {hat eh  Issued.) 

The  hook  is  an  excellent  one,  clear,  concise,  conve-  tive  from  pr-^face  to  the  final  page,  and  ought  to  be 
nient,  practical.  It  is  replete  with  the  very  know-  given  aplac?  on  every  office  table, becnuse  it  contains 
ledge  tne  student  iM^ds  when  heqnitsthe  lecture-  in  acoridensedform  all  that  is  valuable  in  semeiology 
room  and  tbe  laboratory  for  the  ward  and  sick-room,  aud  diagiostics  to  be  f>und  in  balkier  volarat-s,  and 
and  does  not  lack  in  informatioa  that  wili  meet  the  becau^^e  in  its  arrangement  and  complete  index,  it  is 
wants  of  esperienoed  and  older  men. — Phila.  Med.  unusnally  convenient  for  quick  reference  in  any 
Tirnes,  Jan.  4,  1S79.  ;  emergency  that  may  come  upon  thebasy  practitioner. 

This  is  <»Be  rf  tbe  really  useful  books.    It  is  attrac-  |  ~^-  ^-  ^^-  -^""'"a-.  Jan-  1879. 


TTTA  TSON  (THOMAS),  M.D.,  §-c. 

LECTURES    ON    THE     PRINCIPLES    AND    PRACTICE    OF 

PHYSIC.  Delivered  at  King's  College,  London.  A  new  American,  from  the  Fifth  re- 
vised andcElargedEngli.^h  edition.  Edited,  with  additions,  and  several  hundred  illustrn- 
tione.hy  Henry  H.\rtshorse,  M.D.,  Professor  of  Hygiene  in  the  University  of  Penn- 
sylvania.    In  two  large  and  handsome  8vo.  vols.     Cloth,  $9  00;  leather,  $1100. 


WILLIAMS'S   PULMONARY    CONSUMPTION;     its  |    a'ALSHEON  THE  DISEASESOF  THEHE.'iRT  AND 
Nature,  Varieties  and  Treatment.      WiibanAn-'      GREAT  VESSELS.     Third  .^Vmerican  Edition.     In 
alysis  of  One  Thousand  Cases   to  exemplify  its  |      1  vol.  Svo.,  42ri  pp.,  cloth,  $3  00. 
duration.     In   one  neat  «etavo  volume  of  about  i  sMITH  ON  CONSUMPTION  ;  ITS  EARLTAND  BE- 
3.50  pages  ;  el«th,  *2  .10.  MEDIABLE  STAGES.    1  vol.  Kvc.pp.  2.'<4.   «2  25. 

3LADE  ON  DIPHTHERIA;  its  Nature  and  Treat- !  ppLLER  ON  DISE.\SES  OF  THE  LUNGS  AND  AIR- 
m-nt.with  an  iccountof  the  History  of  Its  Pre-j  pass.\GES.  Th^ir  Pat hologv.Phvsical  Diagnosis, 
valeucein  various  Coantrie>  Second  and  revised'  Svmptoios  and  Treatment.  From  the  Second  and 
edmon.  In  one  aeatroyall2mo.  volume,  cloth,  revised  English  edition.  In  one  handsome  octavo 
*^  ■^-  1      volume  of  about  oOO  pages  :  cloth,  $3  50. 


Henry  C.  Lea's  Son  &  Co.'s  Vv^-licatiot^ss— (Practice  of  Iledicine).    IT 
J?EYNOLDS  [J.  RUSSELL).  M.D., 

-*-*'         Prnf.  of  the  Principles  and,  Practice  of  Medicine  in  Univ.  College,  London. 

A  SYSTEM  OF  MRDFnNE   wtth  Notes  and  \ddittons  by  Ht=:nrt  H  arts- 
HORNE,  M.D.,  late  Professor  of  Hygiene  in  the  University  of  Penna.     In  three  Inrge  and 
hnndsome  octavo  volumes,  containing  3052  closely  printed  double-columned  pages,  with 
numerous  illustrations.     Sold  onlyhysiibscri-ption.     Price  per  vol.,  in  cloth,  S5.00  ;   in 
sheep,  S6.00  :  half  Russia,  raised  bands,  $6.50.     Per  set  in  cloth,  $15  ;  sheep,  §18  ;  half 
Russia,  $19.50 
Volume  I.   {just  ready)  contains  Geneeal  Diseases  and  Diseases  of  the  Nervous  System. 
Volume  II.    {jxist  ready)  contains  Diseases  of  Respiratory  and  Circulatory  SYSTEsrs. 
Volume    III.    {just  ready)    contains    Diseases  of   the  Digestive  and  Blood  Glandular 
Systems,  of  the  Urinary  Organs,  of  the  Female  Reproductive  System,  and  of  the 
Cutaneous  System. 
Reynolds's  System  of  Medicine,  recently  completed,  has  acquired,  since  the  first  appearance 
of  the  first  volume,  the  well-deserved  reputation  of  being  the  work  in  which  modern   British 
medicine  is  presented  in  its  fullest  and  most  practical  form.     This  could  scarce  be  otherwise  in 
view  of  the  fact  that  it  is  the  result  of  the  collaboration  of  the  leading  minds  of  the  profession, 
each  subject  being  treated  by  some  gentleman  who  is  regarded  as  its  highest  authority — as  for 
instance.   Diseases  of  the  Bladder  by  Sir  Henry  Thompson,   Malpositions  of  the  Uterus  by 
Graily  Hewitt,  Insanity  by  Henry  Maudsley,  Consumption  by  J.  Hughes  Bennet,   Dis- 
eases of  the  Spine  by  Char-les  Bland  Radclifpe,  Pericarditis  by  Francis  Sibson,  Alcoholism 
by  Francis  E.  Anstie,   Renal  Affections  by  William   Roberts,   Asthma  by  Hyde   ^-'alter, 
Cerebral  Affections  by  H    Charlton  Bastian,  Gout  and  Rheumatism  by  Alfred  Baring  Gar- 
rod,   Constitutional  Syphilis  by  Jonathan  Hutchinson,  Diseases  of  the  Stomach  by  M'^ilson 
Fox,  Diseases  of  the  Skin  by  Balmanno  Squire,   Affections  of  the  Larynx  by  Morell  Mac- 
kenzie, Diseases  of  the  Rectum  by  Blizard  CaRLiNG,   Diabetes  by  Lauder  Brunton,  Intes- 
tinal Diseases  by  John  Syer  Bristowe,  Catalepsy  and  Somnambulism  by  Thomas  King  Cham- 
bers, Apoplexy  by  J.  Hughlings  Jackson,   Angina  Pectoris  by  Professor  Gairdner,  Emphy- 
sema of  the  Lungs  by  Sir  William  Jenner,  etc    etc.     All  the  leading  schools  in  Great  Britain 
have  contributed  their  best  men  in  generous  rivalry,  to  build  up  this  monument  of  medical  sci- 
ence.    St.  Bartholomew's,  Guy's,  St  Thomas's,  University  College,  St.  Mary's,  in  London,  while 
the  Edinburgh,  Glasgow,  and  Manchester  schools  are  equally  well  represented,  the  Army  Medical 
School  at  Netley,  the  military  and  naval  services,  and  the  public  health  boards.     That  a  work 
conceived  in  such  a  spirir,  and  carried  out  under  such  auspices  should  prove  an  indispensable 
treasury  of  facts  and  experience,  suited  to  the  daily  wants  of  the  practitioner,  was  inevitable,  and 
the  success  which  it  has  enjoyed  in  England,  and  the  reputation  which  it   has  acquired  on  this 
side  of  the  Atlantic,  have  sealed  it  with  the  approbation  of  the  two  pre-eminently  practical  nations. 
Its  large  size  and  high  price  having  kept  it  beyond  the  reach  of  many  practitioners  in  this 
country  who  desire  to  possess  it,  a  demand  has  arisen  for  an  edition  at  a  price  which  shall  ren- 
der it  iiccessible  to  all.     To  meet  this  demand  the  present  edition  has  been  undertaken.     The 
five  volumes  and  five  thousard  pages  of  the  original  have,  bj'  toe  use  of  a  smaller  type  and  double 
columns,  been  compres,-ed  into  three  volumes  of  over  three  thousand  pages,  clearly  and  hand- 
somely printed,  and  ofi"ered  at  a  price  which  renders  it  one  of  the  cheapest  works  ever  presented 
to  the  American  profession. 

But  not  only  is  the  Americ.in  edition  more  convenient  and  lower  priced  than  the  English; 
it  is  also  better  and  more  complete.  Some  years  having  elapsed  since  the  appearance  of  a 
portion  of  the  work,  additions  are  required  to  bring  up  the  subjects  to  the  existing  condition 
of  science.  Some  diseases,  also,  which  are  comparatively  unimportant  in  England,  require  more 
elaborate  treatment  to  adapt  the  articles  devoted  to  them  to  the  wants  of  the  American  physi- 
cian ;  and  there  are  points  on  which  the  received  practice  in  this  country  differs  from  that 
adopted  abroad.  The  supplying  of  these  deficiencies  has  been  undertaken  by  Henry  Harts- 
HORNE,  M.D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsylvania,  who  has  endeavored 
to  render  the  work  fully  up  to  the  day,  and  as  useful  to  the  American  physician  as  it  has  proved 
to  be  to  his  English  brethren.  The  number  of  illustrations  has  also  been  largely  increased,  and 
no  effort  spared  to  render  the  typographical  execution  unexceptionable  in  every  respect. 

Really  too  much  praise  can  scarcely  be  givea  to 
this  noble  book.  It  is  a  cyclopeedia  of  medicine 
written  by  .some  of  the  best  men  of  Europe.  It  is 
full  of  usefal  information  such  as  one  finds  frequent 
need  of  in  one's  daily  work  As  a  book  of  reference 
it  is  invaluable.  It  is  up  with  the  times.  It  is  clear 
and  concentrated  in  ^tyle,  and  its  form  is  worthy 
of  its  famous  publisher.  —  Louisville  Med.  News, 
Jan.  31,1SS0. 

"Reynolds'  System  of  Medicine"  is  ju=tly  con- 
sidered the  most  popular  woTk  on  the  principles  and 
practice  of  medicine  in  the  English  language.  The 
contributors  to  this  work  are  gentlemen  of  well- 
known   reputation   on   both   sides    of  the   Atlantic 


subjects  with  which  he  should  be  familiar. — Gail- 
lard's  Med.  Journ.,  Feb.  18S0. 

There  is  no  medical  work  which  we  have  in  times 
past  more  frequently  and  fully  consulted  whea  per- 
plexed by  doubts  as  to  treatment,  or  by  having  un- 
usual or  apparently  inexplicable  symptoms  pre- 
sented to  us  than  "Reynolds'  System  of  Medicine." 
Among  its  contributors  are  gentlemen  who  are  as 
well  known  by  reputation  upon  this  side  of  the 
Atlantic  as  in  Great  Britain,  and  whose  right  to 
speak  with  authority  upon  the  subjects  about 
which  they  have  writteu,  is  recognized  the  world 
over.  They  have  evidently  striven  to  make  their 
es.^ays  as  practical  as  possible,  and  while  these  are 
Each  geurleman  has  striven  to  make  his  part  of  the  '  sufficiently  full  to  entitle  them  to  the  name  of 
work  as  practical  as  pos-ible.  and  the  inforiiiatioa  \  monographs,  they  are  not  loaded  down  with  such 
contained  is  such  as  is  needed  by  the  busy  practi-  I  an  amount  of  detail  as  to  render  them  wearisome 
tiouev.  — St.  Louis  Med.  and  Surg.  Journ.,  J a,n.' 80.  1  to  the  general  reader.     In  a  word,  they  contain  just 

I  tha'  kind  of  information  which  the  busy  practitioner 
Dr.  Hartshorne  has  made  ample  additions  and  frequeotly  finds  himself  in  need  of.  In  order  that 
revisions,  all  of  which  give  increased  value  to  the  i  any  deficiencies  may  be  supplied,  the  publishers 
volume,  and  render  it  more  useful  to  the  Ameri-  have  committed  the  preparation  of  the  book  for  the 
can  practitioner.  There  is  no  volume  in  English  ,  press  to  Dr.  Henry  Hartshorne,  whose  judicious 
medical  literature  more  valuable,  and  every  pur- !  notesdistribnted  throughout  the  volume  afi'ord  abun- 
chaser  will,  on  becoming  familiar  with  it,  congrat-  >  dant  evidence  of  the  thoroughness  of  the  revision  to 
niate  himsfilf  on  the  posspssiop  of  this  vast  store- !  which  he  hassubjected  it. — Am.  Jour. Med.  Sciences, 
house  of  information,  in.  regard  to  so  many  of  the  (  Jan.  18S0. 


18        Henry  C.  Lea's  Son  &  Co.'s  Publications — (Kerv.  Dis  ,  <&c.). 


B 


ARTHOLOW  (ROBERTS),  AM..  M.D..  LL.D. 

Prof.  cfMnte.ria  Medica  nvd  Oone.rnl  ThTapeutics  in  the  Jef  Mfd.  CoH  of  Phila  ,  etc. 

A  PRACTICAL  TPvEATISE  OX  ELECTRICITY  IX  ITS  APPLL 

CATION    TO    MEDICINE.       In  one  very  handsome  8vo.  volume  of  about  270  pages, 
with  98  illustrations.     Cloth,  $2  60.     {Just  re.<idy.) 

EXTRACT  FROM  THE  ADTHOR'S  PREFACE. 

I  have  attempted  in  the  preparation  of  this  work  to  avoid  tbe?e  errors;  to  prepare  on^  .so 
simple  in  statement  that  a  student  without  previous  acquaintance  with  the  .subject,  may  read- 
ily master  the  essentials;  so  complete  as  to  embrace  the  whnle  subject  of  medical  electricity, 
and  so  condensed  as  to  be  complete  in  a  moderate  compass.  I  have  endeavored  to  keep  con- 
stantly in  view  the  needs  of  the  two  classes  for  whom  the  work  is  prepared — students  and  prac- 
titioners. I  have  as'umed  an  entire  unacquaintance  with  the  elements  of  the  subject  as  the 
point  of  departure — for  I  am  addre'sinp;  those  who  have  either  failed  to  acquire  this  prelimi- 
nary knowledge,  or  having  acquired  it,  ficd  that  after  the  lapse  of  years,  it  has  become  misty 
and  confused.  In  the  accounts  of  electr'C.il  phenomena  I  have  alhered  to  the  modes  of  oxpres- 
gion  with  which  the  medical  electrical  text-books  have  made  us  familiar. 

This  bo<^k,  then,  must  be  regarded  as  the  exposition  of  electricity  as  a  remedial  agent,  made 
by  a  medic  >1  practitioner  for  the  use  of  medical  practitioners.  No  claim  is  made  on  the  ground 
of  pure  science.  It  is  believed,  however,  that  the  work  makes  an  adequate  presentation  of  the 
subject,  regarding  electricity  as  a  remedial  agent — as  one  of  the  means  employed  for  the  treat- 
ment and  cure  of  disease. 

.So  far  as  we  know,  the  need  of  a  clear,  fimple,  I  practitioners.  From  this  standpoint  the  work  ia 
nntechDical,  reliable,  concise,  and  modern  treatise  |  worthy  of  the  careful  study  of  all  who  desire  to  'Q- 
np'in  the  tuhject  of  medical  electricity  is  only  cup-  1  vestigaie  this  subject  for  parely  practical  purposes, 
plied  by  the  volume  under  consideralion.  It  is  not  This  work  rneetf  a  want  of  very  many  students  and 
too  much  to  say  that,  if  availed  of.  it  will  render  medical  practitioners.  Wb  greatly  err  if  it  be  not 
accessible  to  a  vast  number  of  niembers  of  the  pro-  I  gladly  welcomed  by  thera.  The  author,  from  his 
fes>ion  a  therapeutic  agent  of  the  greatest  value,  but  \  long  experience  as  a  practitioner,  is  admirably  fitted 
which  has  heretofore  been  practically  of  no  use  ,  to  perfurm  the  task  of  writing  a  work  of  this  kind 
whatever  to  them. — Maryland  Med.  Journal,  June  i  for  this  special  class  of  men. — Detroit  Lancet,  June, 
1,  ISSl.  18S1. 

We  have  not  yet  come  across  a  book  that  can  com-  ]      ^his  book  is  expressive  of  careful  research  and  a 


pare  with  this  in  clearness  and  simplicity  of  state 
ment.  We  have  for  a  long  lime  needed  a  text-book 
on  medical  electricity,  conden.<ed  and  yet  comple'e, 
and  this  want  has  been  well  supplied  by  the  dittin- 
guished  author.     The  illustrations  are  elegant,  and 


nice  discrimination  in  the  selection  of  ^nch  niattpr 
from  that  at  the  author's  command  as  i*  best  ndaped 
for  the  gaidance  and  insfrncti'm  of  the  pbysici5)u 
whose  interest  in  electricity  is  proportionate  lo  its 
practical  bearing  on  diagnosis  and  treatment.     It  is 


the  book  as  a  whole  is  a  valuable  addition  to  the  ,  thorough,  it  is  accurate,  it  is  readable,  and  above 
co.lection  of  any  student  or  rractltioner.-  Bvffalo  ^jj  j^  essentially  ntilizable,  if  we  may  use  the  word, 
Med.  and  Surg.  J.vmal,  June,  1S81.  a„j  renders  easy  ..f  access  to  the  eeneral  practiti.per 

As  a  wh^ile,  the  book  must  be  looked  upon  as  an  |  the  modim  npfrandi  of  employing  this  very  vain- 
exposition  of  electricity  for  remedial  purposes,  writ-  j  able  therapeutic  agent. — N.  Y.  Medical  Gaz.,  June 
ten  by  a  medical  practitioner  for  the  use  of  medical  >  11,  ISSl. 


lif ITCH  ELL  (S.  WEIR).  M.D.. 

•i-'-L         Phyn.  to  Orfhopcedic  Hospital  nndthe  Infirmary  fnr  Dt's.o/thf  yrvous  System,  Phila.,  etc.  etc. 

LECTURES    OX     DISEASES    OF    THE     XERVOUS    SYSTEM, 

ESPECIALLY  IN  WOMEN.     In  one  very  handsome  12mo.  volume  of  about  250  pages, 

with  five  lithographic  plates.  Cloth,  $1  75  (Just  Ready  ) 
The  life-!ong  devotion  of  ibe  author  to  the  subjects  discussed  in  this  volume  has  rendered  it 
eir.inently  c'esir^ble  that  the  results  of  his  labors  should  be  embodied  for  the  benefit  of  those 
who  may  experience  the  difficulties  connected  with  the  treatment  of  this  class  of  disease. 
Many  of  these  lectures  are  fresh  studies  of  hysterical  affections;  others  treat  ot  the  modifica- 
tions his  views  have  undergone  in  regard  to  certain  forms  of  trentment,  while,  throughout  the 
whole  work,  he  has  been  careful  to  keep  in  view  the  practical  le.^sons  of  his  cases. 

It  is  a  record  of  a  number  of  very  remarkable  ,  ordinarily  rich  in  acute  observation  and  sound  in- 
cases, with  acute  analyses  and  discussions,  clinical,  Eiruclion.  The  repuiation  of  the  author  is  a  t;car- 
physioli  gical,  and  therapeutical  It  Is  a  hook  to  aolee  of  that,  and  no  reai  er  will  be  disappointed. 
whi<"h  the  physician  mepting  wi  h  a  new  hysterical  Nor  can  too  mnch  be  sai''  in  praise  of  the  admirab  e 
experience,  or  in  doubt  whether  hia  new  experience  syle  of  hio  m-  dical  writings,  and  each  of  these  ler- 
is  hysterical,  may  well  turn  with  a  well-grounded  tures  reads  with  the  flr,i«hed  grace  of  a  polished 
hi  pe  of  finding  a  parallelism  ;  it  will  be  a  new  ex-  essay.  Indeed,  the  book  through  on  t  is  sO  fascinatins; 
perience,  indeed,  if  no  similar  one  is  here  recorded  a  one  that  it  cmld  not  fail  to  be  read  entire  oy  evei  y 
—  Phila.  Med.  Times,  June  4,  1«S1.  '  one  who  bfgins  its  pages.  —Phila.  Med.  and  Sv-rg. 

The  nnmeof  the  author  is  sufficient  guarantee  that  ;  Ji'V'ri'r,  May  7,  ISSl. 
these  topics  are  ably  and  appreciatively  disrns^ed;  The  book  thronehont  is  not  only  intensely  enfer- 
sutfice.i  to  say  that  the  principles  of  treatment,  both  taiainit.  but  it  contains  a  large  anion  nt  of  rare  and 
hygienic  and  therapeut  c  are  clearly  ludicaied.  valuable  information.  Dr  Mi  chell  has  re^ordM 
The  articles  being  in  the  form  of  ehnical  lectures,  ^ot  onlv  the  resul-s  of  his  most  carefn' observat-on, 
abound  ,n  Illustrative  cases,  and  are  much  ea-ier  b„,  has'added  to  the  knowledge  of  the  .subjects  trea'- 
reading  than  a  syjiemstic  treatise  on  the  same  ed  by  his  original  investigation  and  p.actical  study. 
top^cs.-ColUge  and  Clinual  Record,  May  15, 1^81.  ^  The  book  is  one  we  can  commend  to  all  of  our  read- 

It  is  needless  to  say  that  these  lecinreg  are  extra-  i  era  — Maryland  Med.  Journal,  May  1,  1881. 

fjAMJLTO.y  {ALLAN  MrLANE).  M.D., 

•'■■'■  Attending  Physician  at  the  Hoepitn)  for  Epileptic*  and  Paralytics.  BlackwelVs  Island,  N.  7., 

and  nt  the  Out- I'atienlK'  Df^parlm^'nt  of  the  New  York  HotpUnl. 

NERVOUS  DISEASES;  THEIR  DESCRIPTIOXAXDTREATMEXT. 

Second   edition,   thoroughly  revised   and  rewritten.      In  one  handsome  octavo  volume  of 
about  600  pages,  with  nuicerous  illustrations.     (/«  Press.) 


Henry  C.  Lea's  Son  &  Co.'s  Publications— (Dzs.  of  the  SMn,&G.).    19 


MORRIS  (MALCOLM),  M.D., 

■J-'J-  Joint  Lecturer  on  Dermatology,  St.  Mary's  Hospital  Med.  School. 

SKIN  DISEASES,  Including  their  Definitions,  Symptoms,  Diagnosis, 

Prognosis,  Morbid  Anatomy  and  Treatment.      A  Manual  for  Students  and  Practitioners. 

In  one  12mo.  volume  of  over  300  pages.    With  illustrations.     Cloth,  $1  75.     (NowReady.) 
To  physicians  who  would  like  to  know  something 
about  skin  diseases,  so  that  when  a  patient  present)- 
bimseif  for  relief  they  can  make  a  correct  diagnosis 


and  prescribe  a  rational  trea'ment,  we  unhesitatingly 
recommend  this  little  book  of  Dr.  Morris.  The  affec- 
tions of  the  skin  are  described  in  a  terse,  Incid  man- 
ner, and  their  several  characteristics  so  plainly  set 
foi'th  that  diagnosis  will  be  easy.  The  treatment 
in  each  case  is  such  as  the  experience  of  the  most 
eminent  dermatologists  advise. — Cincinnati  Medi- 
cal News,  April,  ISSO. 

This  is  emphatically  a  learner's  book  ;  for  we  can 
safely  say,  so  far  as  our  judgment  goes,  that  in  the 
whole  range  of  medical  liieraiure  of  a  like  scope 
there  is  no  book  which  for  clearness  of  expression, 
and    methodical  arrangemeut  is   better  adapted  to 


beginner. — Si.    Louis  Courier  of  Medicine,  April, 
1880. 

The  author  of  this  manual  has  evidently  a  full  and 
intimate  acquaintance  with  the  literature  of  derma- 
tology, and  with  the  most  recent  developments  and 
appliances  of  cutaneons  medicine.  He  has  produced 
a  plain,  practical  book,  by  aid  of  which,  who  so 
chooses  may  triin  his  eye  to  the  recoguiiion  of 
light  but  significant  differences.  The  descriptions 
are  neither  too  vaa;ue  nor  over-refined  ;  the  direc- 
tions for  treatment  are  clear  and  succinct. — London 
Brain,  April,  1880 

The  author's  task  has  been  well  done  and  has  pro- 
duced one  of  the  best  recent  works  upon  the  difBcnU 
subject  of  which  it  treats  ;  there  is  no  work  published 
which  gives  a  better  view  of  the  elementary  facts 


F' 


promote   a   rational   conception    of  dermatology,    a    and  nriaciples  of  dermatology.— jVe?.£)  OcZeans  ilfetti 
branch  confessedly  difficult  and  perplexing   to  the  |  cal  and  Surgical  Journal,  April,  1880. 

'OX  (  TILBVRF),  M.D.,  F.R.C.P.,  and  T.  C.  FOX,  B.A.,  M.R.C.S., 

Physician  to  the  Department /or  Skin  Di.teases,  Univer.iity  College  Hospital. 

EPITOME  OF  SKIN  DISEASES.     WITH  FORMULA.    For  Stu- 

DENTS  AND  Practitionkrs.  Second  edition,  thoroughly  revised  and  greatly  enlarged.  In 
one  very  handsome  12mo.  volume  of  216  pages.     Cloth,  $1  38. 

'C^LINT  [A  USTIN) ,  M.D., 

•*•  Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Med.  College,  N.  T. 

A  MANUAL  OP  PEPvCUSSION  AND  AUSCULTATION;  of  the 

Physical  Diagno.»is  of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism. 

Second  edition.     In  one  handsome  royal  12mo.  volume:  cloth,  $1  63.      (Just  Ready.) 

The  little  work  before  us  has  already  become  a  |  author  has  for  miny  yearx  given,  in  connection  with 

standard  one,  and  has  become   extensively  adopted  |  practical  instruction  in  auscultation  and  percussion, 

as  a  te.xt-book.     There  is  certainly  none  better.     If  I  to  private  classes,  composed  of  medical  students  and 

contains   the  substance   of   the   lessons   which   the  1  practitioners.  — Cineiftraaii  .Med.  iVews,  Feb.  1880. 

»r    THE  SAME   AUTHOR. 

PHTHISIS:  ITS  MORBID  ANATOMY,  ETIOLOGY,  SYMPTOM- 
ATIC EVENTS  AND   COMPLICATIONS,  FATALITY  AND  PROGNOSIS,  TREAT 
MENT    AND  PHYSICAL  DIAGNOSIS;   in  a  series  of  Clinical  Studies.     By  Austin 
Flint,  M.D.  ,  Prof,  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Med. 
College,  New  York.     In  one  handsome  octavo  volume  :  $3  50. 

1>F  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OF  DISEASES  OF  THE  HEART.  Second  revised  and  enlarged 
edition.     In  one  octavo  volume  of  550  pages,  with  a  plate,  cloth,  §4. 

■DT  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 
of  595  pages,  cloth,  $4  50.      

jyRO  WN  [LENNOX),  F.R.G.S.  Ed., 

-*-'  Senior  Surgeon  to  the  Ci'ntral  London  Throat  and  Ear  Hospital,  etc. 

THE  THROAT   AND  ITS  DISEASES.     Second  American,  from  the 

Second  English  Edition,  thoroughly  revised.  With  one  hundred  Typical  Illustr:itions  in 
colors,  and  fifty  wood  engravings,  designed  and  executed  by  the  author.  In  one  very 
handsome  imperial  octavo  volume  of  over  350  pages.      (^Preparing.  ) 

^EILER  (CARL),  M.D., 

^  Lecturer  on  Laryngoscopy  at  the  Univ.  of  Penna.,   Chief  of  the  Throat  Dispensary  at  the 

Univ.  Hospital,  Phila.,  etc. 

HANDBOOK  OF  DIAGNOSIS  AND  TREATMENT  OF  DISEASES  OF 

THE    THROAT   AND    NASAL   CAVITIES.      In   one  handsome  royal  12mo.  volume, 

of  156  pages,  with  35  illustrations  ;  cloth,  $1.      (Lately  Issued.) 

We  most  heartily  commend  this  book  as  showing  ,      A  convenient  little  handbook,  clear,  concise,  and 

sound  judgment  in  practice,  and  perfect  familiarity  *  accurate  in  its  method,  and  admirably  fulfilling  its 

with   the  literature  of  tlie  specialty  it  so  ably  epi-  i  purpo.se  of  bringing  the  subject  of  which  it  treats 

tomizns,.— Philada.   Mtd.  Times,  July  5,  IS79.  within   the    comprehension    of  the   general  practi- 

I  tioner. — N  O.  Med.  Jour.,  June,  1879. 

CLINICAL     OBSERVATIONS   ON   PCNCTIONAL  )  HILLIER'S  HANDBOOK  OF  SKIN    DISEASES,  for 
NERVOUS  DISORDERS    B  v  0.  Handfieli)  Jones         Students  and  I'ractitioners.     Second  Am    Ed       In 
M.D.,  Physician  to  St.  Mary's  Hospital,  &c.   Sec-  i      one  royal  12mo.vol.  of  358  pp.  With  illustrations. 
Otld  America  p  Edition.    I  n  one  hd  udsome  ociav(  t      Cloth,  $2  25. 
▼(jlnmeof  3-18  pageb,cloth,$3  23.  1 


20    Henry  C.  Lea's  Son  &  Co.'s  Publications — (  Venereal  Diseases,  &c.). 
jyUMSTEAD  {FREEMAN  J.),  M.D..LL.D., 

^-^         Lnte  Profe.sitor  of  Venereal  Dixea.iea  at  the  Col.  of  Phy.i  and  Surg..  New  York,  Ac. 

THE  PATHOLOGY  AND   TREATMENT  OF  VENEREAL  PIS- 

EASES.  Including  the  resultsof  recent  investigations  upon  the  subject.  Fourth  Edition, 
revised  and  iarg'-ly  rewritten  with  the  co-operation  of  R.  W.  Taylor,  M.D.,  of  New 
York,  Prof,  of  Dermatology  in  the  Univ.  of  Vt.  In  one  large  and  handsome  octavo 
volume  of  8.'?5  pages,  with  138  illustrations.  Cloth,  $4  75  ;  leather,  $5  75;  half  Russia, 
$6  25.      (Now  Ready.) 

VTe  have  to  congratulate    onr  conntrymen   upon  i  will  more  than  repay  him  for  the  outlay. — Archives 
the  truly  valuable  addition  which  they  have  made  i  of  Medicine,  April,  18=^0. 


to  American  literature.  The  careful  esiiraate  of  the 
value  of  the  volume,  which  we  have  made,  justifies 
as  in  declaring  that  this  is  the  best  treatise  on 
venereal  diseases  in  the  English  laugnage.  and  we 
might  add,  if  there  is  a  better  in  any  other  tongue 
we  cannot  name  it;  there  are  certainly  no  books  in 
which  the  student  or  the  general  practitioner  can 
find  snch  an  excellent  ri-^nmi  of  the  literature  of 
any  topic,  and  such  practical  suggestions  regarding 
the  treatment  of  the  various  complications  of  every 
venereal  disease.  We  take  pleasure  in  repeating 
that  we  believe  this  to  be  the  best  treatise  on  vene- 
real disease  in  the  English  language,  and  we  con- 
gratulate the  authors  upon  their  brilliant  addition 
to  American  medical  literature. — Ohiiagii  Med.  Jour- 
nal and  Examiner,  February,  ISSO. 


This  now  classical  work  on  venereal  disease  comes 
to  us  in  its  fourth  ed.tion  rewritten,  enlarged,  and 
materially  improved  in  every  way.  Dr.  Taylor,  as 
we  had  everv  reason  to  expect,  has  performed  this 
part  of  his  work  with  uuusual  excellence.  We  feel 
that  what  has  been  written  has  done  but  scanty  jus- 
tice to  the  merits  of  thi'-  truly  great  treatise.— Sf. 
Louis  Couri^r  of  Medicine,  Feb.  18S0 

We  find  that  we  have  here  practically  a  new  book 
—that  the  statement  of  the  title-page,  as  to  the  fact 
that  it  has  been  largely  rewritten,  is  a  safficieatly 
modest  announcement  for  the  important  changes  in 
the  text,  .\fter  a  thorough  examination  of  the  pre- 
sent edition,  we  can  assert  confidently  that  the  enor- 
mous labor  w*  have  described  has  been  here  most 


,   .         .  ,  .  ,  ,     ,,       .     ,      faithfully  and    conscientiously    performed. — Amer. 

It  IS,  without  exception,  the  most  valuable  single  i  jpurn.  Med.  Sci  ,  Jan.  ISSO 
work  on  all  branches  of  the  subject  of  which  it  treats  I  '  .    .     \ 

in  iiny  language.  The  pathology  is  sound,  the  work  ,."  '^  one  of  the  best  general  treatises  on  venereal 
is,  at  the  same  time,  iu  the  highest  degree  practical,  diseases  with  which  we  are  acquainted,  and  is  espe- 
and  the  hints  that  ha  will  get  from  it  for  the  man-  cially  to  be  recommended  as  a  guide  to  the  treatment 
agement  of  any  one  case,  at  all  obscure  or  obstinate,    '^^  syphilis.— I,o?uio»  Practitioner,  March,  18S0. 


fyROSS  {SAMUEL  W.),  A.M.,  M.D., 

^-^  Lecturer  on  Genilo-Urina-y  and  Venereal  Di.ien.^en  in  the  .Tefer.ion  yfedicnl  College,  Pkila. 

A    PRACTICAL    TREATISE    ON    I.MPOTENCE,    STERILITY 

A'^D  ALLIED  DISORDERS  OF  THE  MALE  SEXUAL  OKG.XN.-^.     In  one  very  hand 
some  octavo  volume  of  1  74  pages,  with  16  illustrations.     Cloth,  $1  50.     (Just  Ready.) 

EXTRACT   FROM  TH"?   AI^THOR's  PREFACK. 

"My  aim  has  been  tosupply,  in  a  compact  form,  practical  and  strictly  scientific  information, 
especially  adapted  to  the  wants  of  the  general  practitioner,  in  regard  to  a  class  of  common  and 
grave  disorders,  upon  the  correction  of  which  so  much  of  human  happiness  depends.  In  the 
ehiipter  on  Sterility,  the  abnormtil  conditions  of  the  semen  and  the  cttuses  which  deprive  it  of 
its  fecundating  properties  are  fully  considered — a  portion  of  the  work  intended  to  supplement 
the  subject  of  sterility  in  the  female.  From  answers  to  letters  addressed  to  many  of  the  most 
prominent  writers  in  this  country  on  gynteoology,  I  find  that,  with  few  exceptions,  the  womivn 
aliine  commands  attention  in  unfruitful  marriages.  The  importance  of  e.xamining  the  husband 
before  subjecting  the  wife  to  operation  will  be  best  appreciated  when  I  state  that  he  is,  as  a 
rule,  at  fault  in  at  least  one  example  in  every  .'ix." 


/1ULLERIER  (J.),  and 

'-'         Surgeon  to  the  Hdpiial  du  Midi. 


I? DMS TEA D  [FREEMAN  J.), 

-*-'        Profexsor  of  Venereal  Di.ie(rjie.<i  in  the  College  of 
Physician.-i  and  Surgeons.  N.  Y 

AN  ATLAS  OF  VENEREAL  DISEASES.  Tianslntcd  and  Edited  hy 

Freeman  J.  Bdmstrad.  In  one  large  imperial  4to.  volume  of  328  pages,  double-columns, 

with  26  plates,  containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of 

life;  strongly  bound  in  cloth.  S17  00  ;   also,  in  five  parts,  stout  wrappers,  at  $.8  per  part. 

Anticipating  a  very  large  sale  for  this  work,  it  is  offered  at  the  very  low  price  of  Three  Dol  • 

IiARS  a  Part,  thus  placing  it  within  the  reach  of  all  who  are  interested  in  this  department  of 

practice.     Gentlemen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without 

delay.     A  specimen  of  the  plates  and  text  sent  free  by  mail,  on  receipt  of  25  cents. 


LEE'S  LECTURES  ON  SYPHILIS  AND  SO.ME 
FORMS  OF  LOCAL  DISEASE  .EFFECTING  PRIN- 
CIPALLY THE  ORGANS  OF  GENERATION.  In 
one  handsome  octavo  volume;  cloth,  •■S'2  2.'). 

CON  DIE'S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES OF  CHILDREN.  Sixth  edition,  revised 
and  augmented.  In  one  large  octavo  volume  of 
nearly  SCO  closely-printed  pages,  cloth,  $5  25  ; 
leather.  gs6  2.'5. 

WILSON'S  STUDENT'S  BOOK  OF  CUTANEOUS 
MEDICINE  and  Diseasrs  op  the  Skim.  In  one 
very  handsome  royal  12mo   volume.     $.'<  .lO. 

CHA.MBERS'S  MANUAL  OF  DIET  AND  REGIMEN 
IN  HE.\LTH  AND  SICKNE.SS.  In  one  handsome 
octavo  volume.     Cloth,  $2  75. 

BASHAM  ON  RENAL  DISEASES:  a  Clinical  Guide 
to  their  Diagnosis  and  Treatment.  With  Illustra- 
tions.  In  onel2mo.  vol.  of  304  pages,  cloth,  42  00. 


LECTURES  ON  THE  STUDY  OF  FEVER.  By  A. 
HrDSo.y,  M.D.,  M.R.I. A.,  Physician  to  the  Meath 
Hospital      In  one  vol   Svo.,  cloth,  >}!2  .'lO. 

A  TREATISE  ON  FEVER.  By  Robert  D.  Lto.vs, 
K.C.C.  In  one  octavo  volume  of  362  pages, cloth 
«2  2.'). 

HILL  ON  SYPHILIS  AND  LOCAL  CONTAGIOUS 
DISORDERS.  In  one  handsome  octavo  volume; 
cloth   i(3  3.T. 

SMITH'S  PRACTICAL  TREATISE  ON  THE  WAST- 
ING DISEASES  OF  INFANCY  AND  CHiLDH-iOD. 
Second  American,  from  the  Second  revised  and 
enlarged  English  edition.  In  one  handsome  octn.- 
vo  volume,  cloth  .  *2  .SO 

LA  ROCHE  ON  PNEUMONIA.  1  Tol.  8vo.,  cloth, 
of  500  pages.    Price,  $3  00. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Dis.  of  Children,  So.).   21 


^MITH{J.  LEWIS),  M.D., 

Clinical  Professor  of  Diseases  of  Ohildren  in  the  Bellemie  Hospital  Med.  College,  N.  T. 

A  COMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF 

CHILDREN.    Fifth  Edition,  thoroughly  revised  and  rewritten.     In  one  handsome  oc- 
tavo volume  of  836  pages,  with  illustrations.     Cloth,  $4  50;   leather,  $5  50;  very  hand- 
some half  Ru.=sia,  raised  bands,  $6.      (Just  Ready.) 
The  opportunity  afforded  the  author  bj'  the  call  for  a  new  edition  of  his  treatise  on  the  Diseases 
of  Children  has  been  taken  advantage  of  to  render  the  volume  in  every  respect  worthy  a  contin- 
uance of  the  profession's  confidence  with  which  it  has  been  favored  in  the  past.     Many  portions 
of  the  work  have  been  entirely  rewritten,  several  additional  diseases  treated  of,  and  much  new 
matter  introduced  :  but  by  the  employment  of  a  more  condensed  style  of  letter,  the  size  of  the 
work  has  not  been  materially  enlarged.     It  will  be  observed  that  the  very  moderate  price  of  the 
previous  edition  has  not  been  increased. 


^EATING  [JOHN  M.),  M.D., 

Lecturer  on  the  Visen.ses  of  Children  nt  the  University  of  Pennsylva.nia,  etc. 

THE  MOTHER'S  GUIDE  IN  THE  MANAGEMENT  AND  FEED- 

ING  OF  INFANTS.     In  one  handsome  12mo.  vol.  of  118  pages.     Cloth,  $1  00.     (Nmv 
Ready. ) 


The  title  of  this  little  book  is  well  chosen,  and  Dr. 
Keating  has  written  a  work  which  should  be  read, 
and  it.s  precepts  followed  by  every  iuielligent  rno- 
ther  in  tbi.s  country.  It  is  free  from  all  technical 
terms,  the  language  is  clear   and   distinct,  and  so 


structing  them  on  the  subjects  here  dwelt  so  thor- 
oughly and  practically  upon.  Dr.  Keating  has  writ- 
ten a  practical  book,  has  carefully  avoided  unne- 
cessary repetition,  and,  I  think,  successfully  ia- 
strncted  the  mother  in  such  details  of  the  treatment 


carefully  written  that  it  caunol  fail  to  become  popu-  of  her  child  as  devolve  upon  her;  he  has  studiously 
lar.  It  has  always  been  a  mooted  question  how  far  omitted  giving  prescriptions,  and  instructs  the  mo- 
it  is  well  to  instruct  the  public,  but  works  like  this  ther  when  to  call  upon  the  doctor,  as  his  duties  are 
one  will  aid  the  physician  immensely,  for  it  saves  totally  distinct  from  hers. — American  Journal  of 
the  time  he  is  constantly  giving  his  patients  in  in-  Obstetrics,  October,  ISSl. 


WrEST  {CHARLES),  M.D., 

Physician  to  the  Hospital  for  Sick  Children,  London,  &c. 

LECTURES   ON  THE  DISEASES  OF  INFANCY  AND    CHILD- 

HOOD.  Fifth  American  from  the  Sixth  revised  and  enlarged  English  edition.    In  one  large 
and  handsome  octavo  volume  of  678  pages.     Cloth,  $4  50  ;  leather,  $5  50. 

^r  THE  SAME  AUTHOR.    ( Lately  Issued.) 

ON  SOME  DISORDERS  OF  THE  NERYOUS  SYSTEM  IN  CHILD- 
HOOD; being  the  Lumleian  Lectures  delivered  at  the  Royal  College  of  Physicians  of 
London,  in  March,  1871.     In  one  volume   small  12mo.,  eloth,  $1  00. 


Dr  THE  SAMS  AUTHOR. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.     Third  Araerican, 

from  the  Third  London  edition.     In  one  neat  octavo  volume  of  about  550  pages,  cloti, 
$3  75 ;  leather,  $4  75. 


S 


AVNE  {JOSEPH  GRIFFITHS),  M.D., 

Physician-Aceoticlieur  to  the  British  General  Hosj)ital,  &C. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDENTS  COM- 

MENCING  MIDWIFERY  PRACTICE.  Second  American,  from  the  Fifth  and  Revised 
London  Edition,  with  Additions  by  E.  R.  HtrTCHiNS,  M.D.  With  Illustrations.  In  one 
neat  12mo.  volume.     Cloth,  $1  25. 


CHURCHILL  ON  THE  PUERPERAL  FEVER  AND 
OTHER  DISEASES  PECULIAR  TO  WOiMEN.  1  vol. 
<?vo.,  pp. -t'jn,  cloth.     $2.50. 

DE  WEES'S  TREATISE  ON  THE  DISEASES  OF  FE- 
MALES. With  illustrations.  Eleventh  Edition, 
with  the  Author's  lastimprovementsaad  correc- 
tions. In  one  octavo  volume  of  536  pages,  with 
plates,  eloth.    $3  00. 


MEIGS  ON  THE  NATURE,  SIGNS  AND  TREAT- 
MENT OF  CHILDBED  FEVER  1  vol.  Svo.,  pp. 
36.n.  cloth.     .$2  00. 

ASHWELL'S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES PECULIAR  TO  WOMEN.  Third  American, 
from  the  Third  and  revised  London  edition.  1vol. 
8vo.,  pp.  52S,  cloth.    $3  50. 


\T7INCKEL  {F.}, 

f  '  Professor  and  Director  of  the  Gynmcoloffical  Clinic  in  the  University  of  RostoeTc. 

A  COMPLETE  TREATISE  ON  THE  PATHOLOGY  AND  TREAT- 
MENT OF  CHILDBED,  for  Students  and  Practitioners.  Translated,  with  the  consent 
of  the  author,  from  the  Second  German  Edition,  by  James  Rkad  Chabwick,  M.D.  In 
one  octavo  volume.     Cloth,  $4  00. 


MONTGOMERY'S  EXPOSITION  OF  THE  SIGNS 
AND  STIMPTOMS  OF  PREGNANCY.  With  two 
exquisite  colored  plates,  and  tiumerOTis  wond-cnts 
In  1  vol. 8vo.,ofnearly  600pp., cloth, $3  76. 


RIGBY'S  SYSTEM  OF  MIDWIFERY.  With  notes 
and  Additionai  illustrations.  Second  Ameriran 
irlition.  One  volnme  octavo, cloth,  422  piiges, 
$2  50. 


22      Henry  C.  Lea's  Son  &  Co.'s  Publications — (Dis.  of  Women). 
/THOMAS  {T.GAILLARD),M.D., 

•*-  Profe.ssor  of  Obstetrics,  *e..  in  the  College  of  Phy»ician/i  and  Surgeons,  N.  T.,  Jte 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN.    Fifth 

Edition,  thoroughly  revised  and  rewritten.     In  one  hirge  and  handsome  octavo  volume 
of  over  800  pages,  with  266  illustrations.     Cloth,  $5;  leather,  §6;  very  handsome  half 
Russia,  raised  bands,  $6  50.      (Just  Ready.) 
The  author  has  taken  advantage  of  the  opportunity  afforded  by  the  call  for  a  new  edition  of 
this  work  to  render  it  worthy  a  continuance  of  the  very  remarkable  favor  with  which  it  has 
been  received.     Every  portion  of  the  work   has  been  carefully  revised,  very  much  of  it  has 
been  rewritten,  and  additions  and  alterations  introduced  wherever  the  advance  of  science  and 
the  increased  experience  of  the  author  have  shown  them  desirable.      At  the  same  time  special 
eare  has  been  exercised  to  avoid  undue  increase  in  the  size  of  the  volume.     To  accommodate 
the  numerous  additions  a  more  condensed  but  v  ry  clear  letter  his  been  used,  notwithstanding 
which,  the  number  of  pages  has  been  increased  by  more  than  fifty.     The  series  of  illustrations 
has  been  extensively  changed  :   many  which  seemed  to  be  superfluous  have  been  omitted,  and  a 
large  number  of  new  and  superic  drawings  have  been  inserted.     In  its  improved  form,  there- 
fore, it  is  hoped  that  the  volume  will  maintain  the  character  it  has  acquired  of  a  standard 
authority  on  every  detail  of  its  important  subject. 

An  examinatioQ  of  the  work  will  satisfy  that  it  is  i  its  author's  lart;e  experienr-e,  but  reflects  his  care- 
one  of  great  merit.  It  is  not  a  mere  corapilation  fnl  study  among  other  auihorities  in  chi.'i  branch, 
froDi  other  works,  but  is  the  fruit  of  the  ripe  '  both  at  home  and  abroad  Dr.  Thomas  is  an  able 
thought,  sound  judgment,  and  critical  observations  and  conscii-ntious  teacher.  His  wriing-  convey 
of  a  le  rned,  scientific  man.  It  is  a  treasury  of  his  meaning  in  the  ^ame  practical  and  instrnctive 
knoiTli^dge  of  the  department  of  medicine  to  which  maQD-T.  The  last  editi'in  of  this  work  is  fresh  from 
it  i-;  devoted  In  its  present  revised  state  it  rer-  hl<  jen,  wiih  decided  chnnge?  aad  imnroveraents 
tainly  holds  a  foremost  position  as  a  gvnfecological  '  over  former  edi'  ioos.  His  book  presents  generally 
work,  and  will  connniie  to  be  regarded  a-^  a  stan-  accepted  facts,  and  a*  a  ^aide '-i  t  he  student  i>  more 
dard  authority  — Cincinnati  Med.  NeiD9,  Dec.  ISSO.     useful  and  reliable  :han  any  work  in  the  language 

This  work  needs  no  introduction  to  any  of  the  on  diseases  of  w. men.  Thi*  la-^t  edition  will  add 
civilized  nations  of  the  world.  The  edition  before  °*'"'  laurels  'o  those  already  won.  — Jfd.  Med. 
us  adds  to   the  streng'h  of  former  volumes.     With     ■^orirn.,  Nov.  1.5,  ISSO. 

Hhe  wisdom  of  a  master  teacher  he  here  gives  the  I  It  ha*  been  enlarged  and  carefully  revised.  The 
results  that,  in  his  judgmen',  are  most  trustworthy  author  has  brought  it  fully  ahrenst  with  the  times, 
at  the  present  time.  In  its  own  place  it  has  no  and  a>-  the  wave  of  gynscological  progression  has 
rival,  because  the  author  is  the  best  teacher  on  this  i  been  widespread  and  rapid  during  the  iwel  ve  years 
subject  to  the  masses  of  the  profession  As  hitherto  '  that  have  elapsed  since  the  issue  of  the  first  edition, 
this  work  will  be  the  text-hook  on  difeases  of  wo-  one  can  conceive  of  the  great  improvement  this  edi- 
men  We  only  wish  that  in  other  branches  of  medi-  tion  must  be  upon  the  esrlier.  It  is  a  condensed  en- 
cine  a<  capable  teachers  could  be  found  to  write  our  i  cyclopedia  of  «yniec  ilogical  mediine.  The  style  of 
te.^t-books. — Detroit  Lancet,  Jan   ISSl.  j  arran«einent,  the  mauerly  ra  inner  in  which  each 

Sluceitsfir>tappearance  twelve  years  Hgo,  until  '  su^^ject  is  treated,  and  the  honest  convictions  de- 
the  pre-ent  dav,  it  ha<  held  a  position  of  high  re-  ^''^''^  ^^"^  pr.bably  thfl  Urt-est  choical  experience 
gard,  and  is  generally  concer'ed  to  be  one  of  the  ,  '°  «ba*  specialty  of  uny  in  this  country,  all  serve  to 
most  practical  and  trustworthy  volumes  ye'  pre-  I  commend  it  in  the  highest  terms  ^o  the  practitioner, 
sented  to  the  physician  and  student  in  the  depart-  i  — Nashville  Journ.  of  Med.  and  Surf/.,  Jaa.  1881. 
meut  ofgynsecology.     The  woik  embodies  not  only 


F 


B 


DIS  [ARTHUR  TT:),  M.D.  Lond.,  F.R.C.P.,  M.R.CS. 

Assist.  Obstetric  Physician  to  Middlesex  Hospital,  late  Physician  to  British  Lying-in  BospUaJ. 

THE  DISEASES  OF  WOMEN.  Including  tlieir  Pathoio^y,  Causa- 
tion, Symptoms,  Diagnosis,  and  Treatment.  A  manual  for  Students  and  Practitioners. 
In  one  handsome  octavo  volume  with  149  illustrations.      {Shortly.) 

ARNES  [ROBERT],  M.D..  F.R.C.F., 

Obstetric  Physician  to  St.  Thomas's  Hoi-pital,  i-e. 

A  CLINICAL  EXPOSITION  OF  THE  MEDICAL  AND  SFRGI- 

CAL  DISEASES  OF  WOMEN.  Second  American,  from  the  Second  Enlarged  and  Revised 
English  Edition.  In  one  handsome  oct,avn  volume,  of  784  pages,  with  181  illustrations. 
Cloth,  $4  50;  leather,  $6  60;  half  Russia,  $6.      (Lately  lis/ied.) 

Dr.  Barnes  stands  at  the  head  of  his  profession  in  plexity  of  the  man  of  mature  years.  —  Canadian 
the  old  country,  and  it  requires  but  scant  scrutiny  Jnurn.  of  Med  Science,  Nov.  1S7S. 
of  his  hook  to  show  that  it  has  been  sketched  by  a  ,  d^  Barnes's  work  is  one  of  a  practical  character, 
master.  It  is  plain,  practical  common  sense  ;  shows  largely  illustrated  fmm  cases  in  his  own  experienre, 
very  deep  research  without  being  pedantic;  is  emi-  ^at  by  no  means  coni  ned  to  such,  as  will  be  learned 
nently  calculated  to  inspire  euthu.-iasm  without  in-  f^om  the  fact  that  he  quotes  from  no  less  than  628 
cnlcaliMg  rashness;  points  out  the  dangers  to  be  medical  authors  in  numerous  countries.  Coming 
avoided  as  well  as  the  success  to  be  achieved  in  the  >om  snch  an  author,  it  is  not  necessary  to  sav  that 
various  operations  connected  with  this  branch  of  j^g  ^^^j,  j^  ^  yaluable  one,  and  should  be  largely 
medicine  :  and  will  do  much  to  smooth  the  nigged  con-ulted  by  the  profession.-^m.  S-'pp  Obstetrical 
path  of  the  young  gynscologist  and  relieve  the  per-  ;  j„„^^    ^^   Britain  and  Ireland,  Oct.  1S78. 

TJODGE  {HUGH  L.),  M.D^, 

Emeritus  Professor  of  Obstetrics,  &c.,  in  the  University  of  Pennsylvania. 

ON  DISEASES  PECULIAR  TO  WOMEN  ;  including  Displacementa 

of  the  Uterus.  With  original  illustrations.  Second  edition,  revised  and  eul.i.rged.  In 
one  beautifully  printed  octavo  volume  of  531  pages,  cloth,  $4  50. 


Henry  C.  Lea's  Son  &  Co.'s  Publications— ( Dis.  of  Women).      23 
JPUMET  [THOMAS  ADDIS),  M.D., 

-*-^  Surgeon  to  thf.  Woman's  Mo xp if  al,  New  York,etn. 

THE  PRIiNCIPLESAND  PRACTICE  OF  GYNECOLOGY,  for  the 

use  of  Students  and  Practitioners  of  Medicine.  Second  Edition.  Thorougly  Revised. 
In  one  hirge  and  very  handsome  octavo  volume  of  875  pages,  with  133  illustrations. 
Cloth,  $6|   leather,  $6  ;  half  Russia,  raised  bands,  $6  50.      {Just  Ready.) 

Preface  to  the  Second  Edition. 
The  unusually  rapid  exhaustion  of  a  large  edition  of  this  work,  while  flattering  to  the  author 
as  an  evidence  that  his  labors  have  proved  acceptable,  hns  in  a  great  measure  heightened  his 
sense  of  responsibility.  He  has  therefore  endeavored  to  take  full  advantage  of  the  opportunity 
afforded  to  him  for  its  revision.  Every  page  has  received  his  earnest  scrutiny;  the  criticisms 
of  his  reviewers  have  been  carefully  weighed  ;  and  while  no  marked  increase  has  been  made  in 
the  size  of  the  volume,  several  portions  have  been  rewritten,  and  much  new  matter  has  been 
added.  In  this  minute  and  thorough  revision,  the  labor  involved  has  been  much  greater  than 
is  perhaps  apparent  in  the  results,  but  it  has  been  cheerfully  expended  in  the  hope  of  rendering 
the  work  more  worthy  of  the  favor  which  has  been  accorded  to  it  by  the  profession. 


In  no  country  of  the  world  has  gynaicology  re- 
ceived more  attention  than  in  America.  It  is,  then, 
wiDh  a  feeling  of  pleasure  that  we  welcome  a  work 
on  diseases  of  women  from  so  eminent  a  gynjecolo- 
gist  as  Dr.  Emmet,  und  the  work  is  essentially  clini- 
cal, and  leaves  a  strong  impre.-s  of  the  author's  in- 
dividuality. To  criticiza,  with  the  care  it  merit?^, 
the  book  throughout,  would  demnnd  far  more  space 
than  is  at  our  command.  In  parting,  we  can  say 
that  the  work  teems  with  original  ideas,  fresh  and 
valuable  methods  of  practice,  and  is  written  in  a 
clear  and  elegant  style,  worthy  of  the  literary  repu- 
tation of  the  country  of  Longfellow  and  Oliver  Wen- 
dell Holmes.— -Brif.  Med.  Journ.    Feb.  21,  18S0. 

No  gynaecological  treatise  has  appeared  which 
contains  an  equal  amount  of  original  and  useful 
matter;  nor  does  the  medical  and  surgical  history 
of  America  include  a  book  mor«  novel  and  useful. 
The  tabular  and  statistical  Information  which  it 
contains  is  marvellous,  both  in  quantity  and  accu- 
racy, and  cannot  be  otherwise  than  invaluable  to 
future  investigators.    It  is  a  work  which  demands 


not  careless  reading  but  profound  study.  Its  value 
as  a  contribution  to  gynsecology  is,  perhaps,  greater 
than  that  of  all  previous  literature  on  the  subject 
combined. — Chicago  Med.  Gaz.,  April  5,  ISSO 

The  wide  reputation  of  the  author  makes  its  pub- 
lication an  event  in  the  gynecological  world  ;  and 
a  glance  through  its  pages  shows  that  it  is  a  work 
to  be  studied  with  care.  .  .  .  It  must  always  be  a 
work  to  be  carefully  studied  and  frequently  con- 
sulted by  those  who  practise  this  branch  of  onr  pro- 
fession.— Land.  Med.  Times  and  Gaz.,  Jan.  10, 18^0. 

The  character  of  the  work  is  too  well  known  to 
require  extended  notice — suffice  it  to  say  that  no 
recent  work  upon  any  subject  has  attained  such 
great  popularity  so  rapidly.  As  a  work  of  general 
reference  upon  the  subject  of  Diseases  of  Women  it 
is  invaluable.  As  a  record  of  the  largest  clinical 
experience  and  observation  it  has  no  equal.  So 
physician  who  pretends  to  keep  up  with  the  ad- 
vances of  this  department  of  medicine  can  afford  to 
be  without  it. — Nashville  Journ.  of  Medicine  and 
Surgery,  May,  1S80. 


nUNCAN  [J.  MATTHEWS),  M.D.,  LL.D.,  F.R.S.E.,  etc. 

CLINICAL    LECTURES    ON    THE    DISEASES    OF   WOMEN, 


Delivered  in  S.nint  Bartholomew's  Hospital..    In  one  very  neat  octavo  Tolume  of   173 
pages.     Cloth,  SI  50.      (Just  Ready.) 

The  author  ia  a  remarkably  clear  lecturer,  and 

bin   discussion  of  symptoms   and   treatment  i>-  full 

and  suggestive.     Ii  will  be  a   work  which  will  not 

fail  to  be  read  with  benefit  by  practitioner.^  as  well 

by  students.  — P/iiia.  Med.  and  Surg.  Reporter, 


They  are  in  every  way  worthy  of  their  author  ; 
indeed,  we  look  upon  them  as  among  ttie  most  valu- 
ab  e  of  his  contribu'ions  They  are  all  np  >n  mat- 
ters of  great  interest  to  the  general  practitioner 
Some  of  thfm  deal  wi;h  sulijects  that  are  not,  as  a 


rule,  adequately  bundled  in  the  text-books;  others  ]  Feb.  7,1880. 


of  them,  while  bearing  upon  topics  that  are  usually 
treated  of  at  length  in  such  works,  yet  bear  such  a 
stamp  of  individuality  that,  if  widely  read,  as  they 
certainly  deserve  to  be,  they  cannot  fail  to  exert  a 
wholesome  restraint  upon  the  undueeagerness  with 
which  many  yo'ing  physicidns  «eem   bent  upon  fol- 


We  have  read  this  book  with  a  great  deal  of 
pleasure.  It  is  full  of  good  things.  The  hints  on 
pathology  and  treai  ment  scattered  through  the  book 
are  sound,  trustworthy,  and  of  great  value.  A 
healthy  scepticism,  a  large  experience,  and  a  clear 
judgment    are    everywhere    manifest.     Instead    of 


lowing  the  wild  teachings  which  so  infe-t  the  gyn»-  bri.^tiing  with  adfice  oi  doubtful  value  and  nn 
oology  of  the  present  da.y.—N.  T.  Med.  ■/'oMrJi.,  j  sound  character,  the  book  is  in  every  respect  a  safe 
March,  1880.  |  guide.— TAe  Londofi  Lancet,  Jan.  21,  1880. 


r>AMSBOTHAM  [FRANCIS  H. 

THE  PRINCIPLES  AND  PRACTICE 


M.D. 

OF  OBSTETRIC  MEDI- 
CINE AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  -author.  With  additions  by  W.  V.  Keating,  M.  D., 
Professor  of  Obstetrics,  &e.,  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  liree 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  rai.^ed 
bands  ;  with  sixty-four  beautiful  plates,  and  numerous  wood-outs  in  the  text,  containing  in 
all  nearly  200  large  and  beautiful  figures.     $7  00 

ARRY  [JOHN  S.),  M.D., 

Obstetrician  to  the  Philadelphia  Hospital,  Vice-Pre.it  of  the  0>>stet.  Sieiety  of  Philadelphia. 

EXTRA-UTERINE    PREGNANCY:    ITS  CLINICAL  HISTORY, 

DIAGNOSIS,    PROGNOSIS  AND    TREATMENT.     In  one  handsome  octavo  volume. 
Cloth,  $2  50.  

/TANNER  [THOMAS  H.),  M.D. 

ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.    First  American 

from  the  Second  and  Enlarged  English  Edition.     With  four  colored  plates  and  illustra- 
tions on  wood.    In  one  handsome  octavo  volume  of  about  500  pages,  oloth,  $4  25. 


P 


24         Henry  C.  Lea's  Son  &  Go.'s  Publications — {Midwifery). 


TEISHMAN  ( WILLIAM),  M.D., 

Regius  Professor  of  Mi/iwiftry  in  the  University  of  Olasgow,  &c. 

A  SYSTEM  OF  MIDWIFERY,  INCLUDIXG  THE  DISEASES  OF 

PREGNANCY  AND  THE  PUERPERAL  STATE.     Third  American  edition,  revised  by 

the  Author,  with  additions  by   John   S.  Parry,  M.D.,  Obstetrician  to  the  Philadelphia 

Hospital,  &c.     In  one  large  and  very  handsome  octavo  volume,  of  733  pages,  with  over 

two  hundred  illustrations.    Cloth,  $4  50;  leather,  $5  50  ;  half  Russia,  $6.    {Just  Ready.) 

Few  works  on  this  subject  have  met  with  as  great    seems  to   require,  and  we  cannot  bnt  admire   the 

a  demand  af  this  one  appears  to   have.     To  judge  :  ability  with  which  the  task  has  been  performed. 

by  the  frequency  with  which  its  author's  views  are  :  We  consider  it  an  admirable  text-book  for  students 

quoted,  and  its  statement.*;  referred  to iu  obstetrical  >  during  their  attendance  upon  lectures,  and  have 

literature,  one  would  judge  thai  there  are  fewphy-  i  great  pleasure  in  recommending  it.    As  an  exponent 

sicians  devoting  much  attention  to  obstetrics  who  i  of  the  midwifery  of  the  present  day  it  has  no  supe- 

are  without  it.     The  author  is  evidently  a  man  of  '  rior  in  the  Englishlanguage. — Canada  Lancet,  3&n. 


ripe  experience  and  conservative  views,  and  in  no 
branch  of  medicine  are  these  more  valuable  than  in 
this. — Ntiv  Reraetiies,  Jan.  ISSO. 

We  gladly  welcome  the  new  edition  of  this  excel- 
lent textbookof  midwifery.     The  former  editions 


1880. 

To  the  American  student  the  work  before  us  must 
prove  admirably  adapted,  complete  in  all  its  parts, 
essentially  modern  in  its  teachings  and  with  dem- 
on^traticius  noted  for  clearness  and  precision,  it  will 


have  been  most  favorably  received  by  the  profes-  gain  in  favor  and  b«  recognized  as  a  work  of  stand- 
sion  on  both  sides  of  the  Atlantic  In  the  prepara-  ard  merit  The  work  caunot  fail  to  be  popular,  and 
tion  of  the  present  edition  the  author  has  made  such  is  cordially  recommended. — N.  0.  Med.  and  Surg. 
alterations   as  the  progress  of  obstetricil   science  '  J'owrre.,  March,  ISSO. 

PLAYFAIR  (  W.  S.),  M.D.,  F.R.G.P., 
Professor  <>f  Obstetric  Medicine  in  King's  College, etc.  etc. 

A  TREATISE  ON  THE  SCIENCE  AND  PRACTICE  OF  MIDWIFERY. 

Third  American  edition,  revised  by  the  author.  Edited,  with  additions,  by  Robert  P. 
Harris,  M.D.  In  one  handsome  octavo  volume  of  about  700  pages,  with  nearly  200 
illustrations.     Cloth,  $4;   leather,  $5;  half  Russia,  $5  50.      {Just  Ready.) 

The  medical  profession  has  now  the  opportunity  |  a  very  intelligent  idea  of  them,  yet  all  details  not 
of  adding  to  their  stock  of  standard  medical  works     neee'^sary  for  i  full  understanding  of  the  subject  are 
one  of  thebest  volnmeson  midwifery  ever  published,     omitted. — Cincinnati  Med.  New-9,  Jan.  ISSO. 
The  subject  is  taken  up  with  a  master  hand.     The  |      The  rapiditv  with  which  one  edition  of  this  work 
part  devoted  to  laborin  all  its  various  pre.^^entations,  (  follows  another  is  proof  alike  of  its  excellence  and 


the  management  and  results,  is  admirably  arranged, 
and  the  views  entertained  will  be  found  essentially 
modern,  and  the  opinions  expressed  trustworthy 
The  work  abounds  with  plates,  illustrating  various 
obstetrical  positions;  they  are  admirably  wrought, 
and  afford  great  assistance  to  the  student. — N.  0. 
Med.  and  Surg.  Journ.,  March,  TS80. 

If  inquired  of  by  a  medical  student  what  work  on 
obstetrics  we  should  recommend  for  him,  as  par 
excellence,  we  would  ncdoubtedly  advise  him  to 
choose  Playfair's.  It  is  of  convenient  size,  bnt  what 
is  of  chief  importance,  i's  treatment  of  the  various 
subjects  is  concise  and  plain.  While  the  discussions 
and  descriptions  are  sufficiently  elaborate  to  render 


of  the  estimate  that  the  profession  has  formed  of  it. 
It  is  indeed  so  well  known  and  so  hii,'hly  valued 
that  nothing  need  be  said  of  it  as  a  whole.  All 
things  considered,  we  regard  this  treatise  as  the  very 
best  on  Midwifery  in  the  English  language. — N.  Y. 
MedicalJournnl^ Ma.y,  ISSO 

It  certainly  is  an  admirable  exposition  of  the 
Science  and  Practice  of  Midwifery.  Of  course  the 
additions  made  by  the  American  editor.  Dr.  R.  P. 
Harris,  who  never  utters  an  idle  word,  and  whose 
studious  re^earches  in  some  special  departments  of 
obstetrics  are  so  well  known  to  the  profession,  are 
of  great  value. — The  American  Practitioner,  April, 
1880. 


jyARNES  (FANCOURT),  M.D., 

-*-'  Physician  to  the  General  Lying-in  Hospital.  London. 

A  MANUAL  OF  MIDWIFEPvY  FOR  MIDWIVES  AND  MEDICAL 

STUDENT  >.      With   50  illnstrations.     In  one  neat  royal  12mo.  volume  of  200  pages; 
cloth,  $1   25.     {Now  Ready.) 


P 


ARVIN  [THEOPHILUH],  31.1)., 

Prof,  of  Obstetrics  and  of  the  Med.  and  Surg.  Diseases  of  Women  t  Ji  the  Med.  Coll.  of  Indiana . 

A    TREATISE    ON    MIDWIFERY.      In  one  very  handsome  octavo 

volume  of  about  550  pages,  with  numerous  illustrations.      {Preparing.) 


TJODGE  [HUGH  L.),  M.D. , 

Emeritus  Professor  of  Midwifery,  &c.,inthe  University  of  Pennsylvania,  &c. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.     Illus- 

trated  with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.    In  one  large  and  beautifully  printed 
quarto  volume  of  550  double-columned  pages,  strongly  bound  in  cloth,  $14. 
The  work  of  Dr.  Hodge  is  something   more  than 

a  simple  presentation  of  his  particular  views  in  the 

de  )artment   of  Obstetrics;    it  is   something  more 


than  an  )rdinary  treatise  on  midwifery;  it  is,  in  fact, 
a  cyclopajdia  of  midwifery.     He  has  aimed  to  em- 


body in  a  single  volume  the  whole  science  and  art  of 
Obstetrics,  in  elaborate  text  is  combined  with  ac- 
curate and  varied  pictorial  illustrations,  so  that  no 
fact  or  principle  Is  left  unstated  or  unexplained. 
—Am.  Med.  Times,  Sept.  3,  1864. 


^*^  Specimens  of  the  plates  and  letter-press  wiU  be  forwarded  to  any  address,  free  by  mail, 
on  receipt  of  six  cents  in  postage  stamps. 


o 


'HAD  WICK  {JAMES  R.),  A.M.,  M.D. 

A  MANUAL  OF  THE   DISEASES  PECULIAR  TO  WOMEN. 

neat  volume,  royal  12mo.,  with  illustrations.     {Prepari7ig.) 


In  one 


Henry  C.  Lea's  Son  &  Co.'s  Pvbjacations— (Surgery). 


25 


// 


'AMILTON  {FRANK  H.)  M.D.,  LL.D., 

fiurgeon  to  the  Bf.llevue  Untipital.  New  York. 

A  PRACTICAL  TREATISE  ON  FRACTURES  AND  DISLOCA- 

TIONS      Sixth  Edition,  thoroughly  revised,  and  mu.-h  improved.     In  one  very  handsome 
octavo  volume  of  over  900  pages,  with  352   illustrations.     Cloth,  $6  50;    leather,   S6  50; 
half  Russia,  raised  bands,  $7  00.      {Just  Ready.) 
So  many  kind  expression;-;  ol' •welcome  have  been 
showered  upon  each  successive  edi  ion  of  this  val- 
uable treatise,  that  scarcely  anyihing  remains  for 


to  do  but  to  expend  the  customary  cordial  greet 
ing.  It  is  the  only  complete  -work  on  the  subject 
of  Fractures  in  the  English  language-  We  con- 
gratulate the  accomplished  author  on  the  deserved 
8ucce!-s  of  his  tvork,  and  hope  tha;  he  may  live  to 
havemany  .succeeding  editions  pass  under  his  skill- 
ed supervision. — Phila.  Coll.  and  Clin.  Record, 
Nov.  15,  ISSO. 

Universal  verdict  has  pronounced  it,  humanly 
speaking,  a  perfect  treat  se  upon  this  subject.  As 
it  is  the  only  complet'  and  illustrated  ivork  in  any 
language  treating  of  fractures  and  dislocations,  it 
i.s  safe  to  affirm  that  every  wide-awake  surgeon  and 
general  practitioner  will  regard  it  as  indispensable 
to  the  safe  and  pleasant  conduct  of  tht-ir  profes- 
sional work. — Detroit  Lancet,  Ifov.  IS,  1>S0. 


Dr  Hamilton  has  devoted  great  labor  ;o  the  study 
of  these  S'lbjects.  His  large  experience,  extended 
research,  :<nd  patient  investigation  have  made  him 
one  of  the  highest  authorities  among  living  writers 
in  this  branch  of  surgery.  This  work  is  systematic 
and  practical  in  Its  arrangement,  ana  presents  its 
subject  matter  clearly  and  forcibly  to  the  reader 
or  student. — 3Iaryland  Medical  Journal.  Nov. 15 
1S80. 

The  only  complete  work  on  its  subject  in  theEng 
lish  tongue,  and,  indeed,  may  now  be  said  to  be 
the  only  work  of  its  kind  in  any  tongue.  It  would 
require  an  exceedingly  critical  examiaation  to  de- 
tect in  it  any  particulars  in  which  t  might  be  im- 
proved. The  work  is  a  monument  toArnerican 
surgery,  and  will  long  serve  to  keep  green  ihe 
memory  of  its  venerable  SLuthoi.—  Michigan  Med. 
News,  Nov.  10,  ISSl. 


A  SHHURST  {JOHN,  Jr.),  M.D., 

•*^  Prof,  nf  Clinical  Surgery,  Univ-  of  Pa.,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia 

THE    PRINCIPLES  AND  PRACTICE  OF  SURGERY.     Second 

Edition,  enlarged  and  revised.  In  one  very  large  and  handsome  octavo  volume  of  over 
1000  pages,  with  542  illustrations.  Cloth,  $6;  leather,  $7;  half  Russia,  $7  50.  {Just 
Issiced.) 

language  all  that  is  necessary  to  be  learned  by  the 
student  of  surgery  whilst  in  attendance  upon  lec- 
tures, or  the  general  practitioner  in  his  dajly  routine 
practice.— Jf'i.  Med.  .Jnurnal,  Jan.  1S79.- 


Conscientiousness  and  thoroughness  are  two  very 
marked  traits  of  character  in  the  author  of  this 
book.  Out  of  these  traits  largely  has  grown  the 
success  of  his  mental  fruit  In  the  past,  and  the  pre- 
sent offer  seems  in  no  wise  an  exception  to  what  has 
gone  before.  The  general  arrangement  of  the  vol- 
ume is  the  same  as  in  the  first  edition,  but  every  part 
has  been  carefully  revised,  and  much  new  matter 
added.— PAiZa.  Med.  Times,  Feb.  1,  1S79. 

The  favorable  reception  of  the  first  edition  is  a 
guarantee  of  the  popularity  of  this  edition,  which  is 
fresh  from  the  editor's  bands  with  many  enlarge- 
ments and  improvements.  The  author  of  this  work 
is  deservedly  popular  as  an  editor  and  writer,  and 
his  contributions  to  the  literature  of  surgery  have 
gained  for  him  wide  reputation.  The  volume  now 
offered  the  profession  will  add  new  laurels  to  those 
already  won  by  previous  contributions.  We  can 
only  add  that  the  work  is  well  arrangt^d,  filled  with 
practical  matter,  and  contains  in   brief  and  clear 


The  fact  that  this  work  has  reached  a  second  edi- 
tion so  very  soon  after  the  publication  of  the  first 
one,  speaks  more  highly  of  its  merits  than  anything 
we  might  say  in  the  way  of  commendation.  It 
seems  to  have  immediately  gained  the  favor  of  stu- 
dents and  physicians. — Cinc-in.  Med.  News,  Jan.  '79. 

We  have  previously  spoken  of  Dr.  Ashhurst's 
work  in  terms  of  praise.  We  wish  to  reiterate  those 
terms  here,  and  to  add  that  no  more  satisfactory 
representation  of  modern  surgery  has  yet  fallen 
from  the  press.  In  point  of  judicial  fairness,  of 
power  of  condensation,  of  accuracy  and  conciseness 
of  expres.sion  and  thoroughly  good  English,  Prof. 
Ashhurst  has  no  superior  among  the  surgical  writers 
in  America. — Am.  Practitioner,  Jan.  1S79. 


^TIMSON  {LEWIS  A.),  A.M.,  M.D., 

^  Sii.rgeon  to  the  Presbyterian  Hospital. 

A  MANUAL  OF  OPERATIVE  SURGERY.     In  one  very  handsome 

royal  12mo.  volume  of  about  500  pages,  with  332  illustrations  ;  cloth,  $2  50. 

The  work  before  us  is  a  well  printed,  profusely  performing  them.  The  work  is  handsomely  illus- 
illustrated  manual  of  over  four  hundred  and  seventy  '  trated,  and  the  defcriptionsareclear  and  well  drawn, 
pages.  The  novice,  by  a  perusal  of  the  work,  will  It  is  a  clever  and  useful  volume  ;  every  student 
gain  a  good  idea  of  the  general  domain  of  operative  i  should  possess  one.  The  preparation  of  this  work 
surgery,  while  the  practical  surgeon  has  presented  does  away  with  the  necessity  of  pondering  over 
to  him  within  a  very  concise  and  intelligible  form  i  larger  works  on  surgery  for  desciiptions  of  opera- 
the  latest  and  most  approved  selections  of  operative  I  tions,  as  it  presents  in  a  nut-shell  just  what  is  wanted 
procedure.  Theprecision  ard  conciseness  with  which  by  the  surgeon  without  an  elaborate  search  to  find 
the  difi'erent  operations  are  described  enable  the  it. — Md.  Med  Journal,  Aug.  1S7S. 
author  to  compress  an  immense  amount  ot-^practical  rj-j^g  author's  conciseness  and  the  repleteness  of 
information  ma  very  small  compass.— i«^.  X.  Meaieal  \  ^^^  ^^^.j,  .j^jfij  valuable  illustrations  entitle  it  to  be 
Record,  Aug.  3,  ISiS.  j  classed  with  the  text-books  for  students  of  operative 

This  volume  is  devoted  entirely  to  operative  sur- '  surgery,  and  as  one  of  reference  to  the  practitioner, 
gery,  and  is  intended  to  familiarize  the  student  with  i  — Cincinnati  Lancet  and  Clinic,  July  27, 1S7S. 
the  details  of  operations  and  the  difi'erent  modes  of  i 


SKEY'S  OPEKATIVE  SUKGEKY.  In  1  vol.  8vo. 
cl.,  of  6.50  pages  ;  with  about  100 wood-cuts.  $3  25. 

COOPEK'S  LECTUEES  OK  THE  PRINCIPLES  AND 

PracticeofSueoebt.  Inl  vol.  Svo.crh,750p.  $2. 

GIBSON'S  INSTITUTES  AND  PKACTICE  OF  SDR- 
GERT.  Eighth  edit'n,  improved  and  altered.  With 
thirty-four  plates.  In  two  handsome  octavo  vol- 
umes, about  1000  pp..  leather,  raised  ban dF.  $6  50. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY. 
By  William  Pibrie,F.R  S.E.,  Profes'r  of  Surgery 
in  the  University  of  Aberdeen.    Edited  by  John 


Neill,  M.D.,  Professorof  Surgery  in  the  Penna. 
MedicalCollege,Surg'n  to  the  Pennsylvania  Hos- 
pital, &c.  In  one  very  handsome  octavo  vol.  of 
780  pages,  with  316  illustrations,  cloth,  $3  75. 

MILLER'S  PRINCIPLESOF  SURGERY.  Fourth  Ame- 
rican, from  the  Third  Edinburgh  Edition.  In  one 
large  8vo.  vol.  of  700  pages,  with  340  illustratious 
cloth,  $3  75.  ' 

MILLER'S  PRACTICE  OF  SURGERY.  Fourth  Ame- 
rican, from  the  last  Edinburgh  Edition  Revised  by 
the  American  editor.  In  o  ne  large  St-o.  vol.  of  nearly 
TOO  pages,  with  364  illustrations:  cloth,  $3  76. 


26 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Surgery). 


6yR0SS  {SAMUEL  D.),  M.D., 
'  Professor  of  Surgery  in  the,  Jeferson  Medical  College  of  Philadelphta. 

A  SYSTEM  OF  SURGERY :  Pathological,  Diagnostic,  Therapeutic 

and  Operative.  Illustrated  by  upwards  of  Fourteen  Hundred  Engravings.  Fifth  editioE  , 
carefully  revised  and  improved.  In  two  large  and  beautifully  printed  imperial  octavo  vol- 
ume.<  of  about  2300  pp.,  strongly  bound  in  leather,  with  raised  bands,  $15;  half  Russia, 
raised  bands,  $16. 


We  tiave  selUum  read  a  work  with  the  practical 
value  01  which  we  have  beeu  m ore im pressed.  Every 
chapter  is  30  conci.sely  put  together,  that  the  busy 
practitioner,  when  in  difficulty,  can  at  once  find  the 
information  he  requires.  His  work  i.s  cosmopolitan, 
the  surgery  ot  the  world  being  fully  represented  in  it. 
The  work,  in  fact,  is  so  historically  unprejudiced,  and 
so  eminently  practical, that  it  is  almost  a  false  compli- 
ment to  say  tiiatwe  believe  it  to  be  destined  to  occupy 
a  foremost  place  as  a  work  of  reference,  while  a  system 
of  surgery  like  the  present  sy.stem  of  surgery  is  the 
practice  of  surgeons.  The  printingand  binding  of  the 
work  is  unexceptionable;  indeed,  it  contrasts,  in  the 
latter  pe^ipei-t,  remarkably  with  English  medical  and 
surgical  cloth-bound  publications,  which  are  generally 
so  wretchedly  stitched  as  to  require  re- binding  before 
they  are  any  time  in  ase.— Dub.  Journ.  of  Med.  Sci.. 
March,  1874. 

l)r.  Gross's  Surgery,  R  great  work,  has  become  still 
greater,  both  in  size  and  merit,  in  its  most  recent  form. 
Tlie  difference  in  actual  number  of  pages  is  not  more 
than  130,  but.  the  size  of  the  page  having  been  in- 
creased to  what  we  believe  is  technically  termed  •■ele- 
phant,"there  has  been  roomforconsiderableadditions, 
which,  together  with  the  alterations,  are  improve- 
ments,— Loiid.  Lancet. yoy.  16,1872. 

It  combines,  as  perfectly  as  possible,  the  qualities  of 
a  text-book  and  work  of  reference.  We  think  this  last 
edition  of  Gross's  "Surgery,"  will  confirm  his  title  ol 


■'  Primus  inter  Pares."  It  is  learned,  scholar-like,  me- 
thodical, precise,  and  exhaustive.  We  scarcely  think 
any  living  man  could  write  so  complete  and  faultless  a 
treatise,  or  comprehend  more  solid,  instructive  matter 
in  the  given  number  of  pages.  The  labor  must  have 
been  immense,  and  the  work  gives  evidence  of  great 
powers  of  mind,  and  the  highest  order  of  intellectual 
discipline  and  methodical  disposition  and  arrangement 
of  acquired  knowledge  and  personal  experience. — iY.F. 
Med.Jown..¥eh  1873. 

As  a  whole,  we  regard  the  work  as  the  representative 
"System  of  Surgery"  in  the  English  language. — St. 
Louis  Medical  and  Surg.  Journ.,  Oct.  IS''!. 

The  two  magnificent  volumes  before  us  afford  a  very 
complete  view  of  the  surgical  knowledge  of  the  day. 
Some  years  ago  we  had  the  pleasure  of  presenting  the 
first  edition  of  Gross's  Surgery  to  the  profession  as  a 
work  of  unrivalled  excellence;  and  now  we  have  the 
result  of  years  of  experience,  labor.and  study,  all  con- 
densed upon  the  great  work  before  us.  And  to  students 
or  practitioners  desirousof  enriching  theirlibrary  with 
a  treasure  of  reference,  we  can  simply  commend  the 
purchase  of  these  two  volumes  of  immense  research  — 
Cincinnati  Lancttand  Ob-orrvr,  Sept.  1^72. 

A  complete  system  of  surgery — not  a  mere  text-book 
of  operations,  but  asclentific  accountof  surgical  theory 
and  practicein  all  its  departments. — Brit,  and  For. 
Med.  Ckir.  Rev.,  Jan.  1873. 


JOY  THE  SAME  AUTHOR. 

A    PRACTICAL  TREATISE 


ON  THE   DISEASES,  INJURIES 


eases  of  the  urinary  organs. — Atlanta  Med.  Journ., Oct. 
1876. 


and  Malformations  of  the  Urinary  Bladder,  the  Prostate  Gland  and  the  Urethra.    Third 
Edition,  thoroughly  Revised  and  Condensed,  by  Samuel  W.  Gross,  M.D.,  Surgeon  to 
the  Philadelphia  Hospital.  In  one  handsome  octavo  volume  ol674  pages,  with  170  illus- 
trations: cloth,  $4  60. 
For  reference andgeneral  information,  the  physician 
orsurgeon  can  fiud  noworkthat  meets theirnecessilies 

more  Thoroughly  than  this,  a  revised  edition  of  an  ex-  jj  jg  ^j^ij  pleasure  we  now  again  take  up  this  old 
eel  lent  treatise,  and  no  medical  library  should  be  with-  ^^^k  in  a  decidedly  new  dress.  Indeed,  it  must  be  re- 
out  it.  Replete  with  handsome  illustratmns  and  good  ,  garded  as  a  new  book  in  very  many  of  its  parts.  The 
ideas,  it  has  the  unusual  advantage  of  being  easily  i^^^ptgrj;  on  -Diseases  of  the  Bladder,"  "Prostate 
cnmpreheuded.by  the  reasonableand  practical  manner  gody,"  and  "Lithotomy,"  are  splendid  specimens  of 
in  which  the  various  subjects  are  syi,tematized  and  descriptive  writing:  while  the  chapter  on  "Stricture" 
arranged  We  heartily  recommend  it  to  the  profession  ,  j^,  Q^g  of  the  most  concise  and  clear  that  we  have  ever 
as  a  valuableadditiontotheimportantliteratureofdis-iread.— iS'etc  Fork  Med.  Journ. ,i\oy  .IS't. 


THE 


jyr  THE  SAME  AUTHOR. 

A   PRACTICAL   TREATISE    ON   FOREIGN   BODIES    IN 

AIR-PASSAQES.     In  1  vol.  8vo.,  with  illustrations,  pp.  468,  cloth,  $2  75. 

pOLEMAN {ALFRED),  L.R.C.P.,  F.R.C.S.,  L.D.S.,  etc. 

Senior  Denial  Surgeon  and  Lecturer  on  D.ntal  Surgery  to  St.  Bartholomew'' 8  Hospital  and  the 
Dental  College  of  London. 

A    MANUAL    OF    DENTAL     SURGERY    AND    PATHOLOGY. 

Thoroughly  revised  and  adapted  to  the  use  of  American  students,  by  Thomas  C.  Stell- 
wagen,  M.  A.,  M.D.,  D.D.S.,  Professor  of  Physiology  at  the  Philadelphia  Dental  College. 
In  one  handsome  volume  with  about  460  illustrations.     {In  Fress.) 

fiRUITT  {ROBERT),  M.R.C.S.,  !rc. 

THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY. 

A  newand  revised  American,  from  the  Kighth enlarged  and  improved  London  edition.  Illus- 
trated with  four  hundred  and  thirty-two  wood  engravings.    In  one  very  handsome  octavo 
volume,  of  nearly  700  large  and  closely  printed  pages,  cloth,  $4  00  ;  leather,  $5  00. 
InMr.Druitt's  book,  though  contaiDiog  only  some    camay  that  thissaccessis  well  merited.  His  book, 
seven  hundred  pages,  both  the  principles  and  the    moreover,  possesses  the  inestimable  advantages  of 
practice  of  surgery  are  treated,  and  so  clearly  and  I  having  the  subjects  perfectly  well  arranged   and 
perspicuously, as  toelncidate  everyimportint  topic. !  classified   and  of  being  written  in  a  style  at  once 
We  aave  examined  the  book  most  thoroughly,  anc  I  clear  md  sncclnct. — Am.  Journal  of  Med.  Sciences 


ASHTON  on  THE  diseases,  INJURIES,  and  MAL- 
FORMATIONS OF  THE  RECTUM  AND  ANUS: 
with  remarks  on  Habitual  ConBtipdtion.  Second 
American,  from  the  Fourth  and  enlarged  London 
Edition  With  illustrations.  In  one  8vo.  vol.  ot 
287  pages,  cloth, $3  26. 


SARGENT  ON  BANDAGING  ANDOTHER  OPERA- 
TIONS OF  MINOR  SURGERY.  New  edition,  with 
an  additional  chapter  on  Military  Surgery.  One 
l2mo.  vol.  of  383pag98  withlSl  wood-cuts  Cloth, 
$175. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Surgery). 


21 


TJOLMES  ( TIMO  THY),  M.  A ., 

■'--*-  Surgeon  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

A  SYSTEM  OF  SURGERY;  THEORETICAL  AND  PRACTICAL. 

In  Treatises  bv  taeious  authors.  American  Edition,  Thoroughly  revised  and 
REWRITTEN  bT  John  H  Packard,  M.D.,  Surgeon  to  the  Episcopal  and  St.  Joseph's  Hospi- 
tals, Philadelphia,  assisted  by  a  Inrge  corps  of  the  most  eminent  American  surgeons.  In 
three  large  and  very  handsome  imperial  octavo  volumes  of  about  iOfiO  pages  each,  with  over 
1000  illustrations  on  wood  and  thirteen  lithographic  plates,  beautifully  colored.  (So/d 
onhj  by  snbscnption.)  Price  per  volume,  in  cloth,  §6  00;  in  leather,  §7  00;  in  half 
Russia,  $7  50.  Per  set,  in  cloth,  $18  00  ;  in  leather,  $21  00  ;  in  half  Kussia,  $22  60. 
Volume  I.   f,now  ready)   contains    General    Pathology,    Morbid    Processes,  Injuries   in 

General,  Complications  of  Injuries  and  Injuries  of  Regions. 
Volume  II.   {nearly  ready)  contains  Diseases  of  Organs  of  Special  Sense,  Circulatory 

System,  Digestive  Tract  and  Genito-urinary  Organs. 
Volume  III.   {shortly)  contains  Diseases  op   the  Respiratory  Organs,  Joints,  Bones,  and 
Muscles,  Operative  and  Minor  Surgery,  Gunshot  Wounds,  Hospitals  and  Miscel- 
laneous Subjects. 
This  great  work,   issued  some  years  since  in  England,  has  won  such  universal  confidence 
wherever  the  language  is  spoken,  that  its    republication    here,  in   a   form    more   thoroughly 
adapted  to  the  wants  of  the  American  practitioner,  has  seemed  to  be  a  duty  owing  to  the  pro- 
fession. 

To  accomplish  this,  the  aid  has  been  invited  of  thirty-three  of  the  most  distinguished  gentle- 
men, in  eTery  part  of  the  country,  and  for  more  than  a  year  they  have  been  assiduously  engaged 
upon  the  task.  Though  the  original  work  presents  the  combined  labor  of  the  most  eminent 
members  of  all  the  most  prominent  schools  of  England,  yet  the  lapse  of  time  since  the  appear- 
ance of  the  last  edition,  the  progress  of  science,  and  the  peculiarities  of  American  pratice, 
have  rendered  necessary  a  most  careful,  thorough,  and  searching  revision.  Each  article  has 
been  placed  in  the  hands  of  a  gentleman  specially  competent  to  treat  its  subject,  and  no  labor 
has  been  spared  to  bring  each  one  up  to  the  foremost  level  of  the  times,  and  to  adapt  it  thur 
oughly  to  the  practice  of  the  country.  In  certain  cases,  this  has  rendered  necessary  the  sub- 
stitution of  an  entirely  new  essay  for  the  original,  as  in  the  case  of  the  articles  on  Skin  Disea.^es, 
and  on  Diseases  of  the  Absorbent  System,  where  the  views  of  the  authors  have  been  superseded 
by  the  advance  of  medical  science,  and  new  articles  have  therefore  been  prepared  by  Drs.  Arthur 
Van  Harlingen  and  S.  C.  Busey,  respectively.  So  also  in  the  case  of  Anaesthetics,  in  the  use 
of  which  American  practice  differs  from  that  of  England,  the  original  has  been  supplemented 
with  a  new  essay  by  J.  C.  Reeve,  M.D. ,  treating  not  only  of  the  employment  of  ether  and 
chloroform,  but  of  the  other  an£esthetic  agents  of  more  recent  discovery.  The  same  careful 
and  conscientious  revision  has  been  pursued  throughout,  leading  to  an  increase  of  nearly  one- 
fourth  in  matter,  while  the  series  of  illustrations  has  been  more  than  doubled,  and  the  whole 
is  presented  as  a  complete  exponent  of  British  and  American  Surgery,  adapted  to  the  daily 
needs  of  the  working  practitioner 

In  order  to  bring  it  within  the  reach  of  every  member  of  the  profession,  the  five  volumes  of 
the  original  have  been  compressed  into  three,  by  employing  a  double-columned  imperial  octavo 
page,  and  in  this  improved  form  it  is  offered  at  less  than  one  half  the  price  of  the  original.  It 
is  beautifully  printed  on  handsome  laid  paper  and  forms  a  worthy  companion  to  Reynolds's 
"  System  of  Medicine,"  which  has  met  with  so  much  favor  in  every  section  of  the  country. 

The  work  will  be  sold  by  subscription  only,  and  in  due  time  every  member  of  the  profession 
will  be  called  upon  ana  offered  an  opportunity  to  subscribe. 

The  few  notices  appended  will  serve  to  indicate  the  hearty  approval  accorded  to  the  unrevised 
edition  on  its  appearaice  some  years  since; — 


There  is  so  mucti  that  is  instruciive,  even  to  the 
experienced  prdCtitioner,  in  their  practical  and  dis- 
criminating manner  of  aealing  with  mooted  ques- 
tions, none  of  which  seem  to  be  neglected;  their 
abandant  illastralioiis,  dra.5Vn  at  once  from  an  un 
limiled  field  of  hospital  experience,  and  their  candid 
and  sensible  mode  of  handling  the  whole  subject, 
that  these  particular  portions  of  the  work  possess  a 
value  which  places  them  far  above  any  publication 
on  the  same  topics  yet  issued  in  the  langUKge.— .4T/i 
Journ.  Mtd.  Sciences.  ^ 

The  enumeration  of  the  treatises,  and  the  names 
of  tlie  surgical  writers  from  whose  pens  they  pro- 
ceed, s-uffice  to  show  that  this  is  no  ordinary  book, 
and  that  in  the  thousand  pages  of  this  goodly  volume 
lies  a  store  of  information  such  as  Uj  other  surgical 
wjrk  in  the  language  can  pretend  to  offer.  Tbo.'-e  wLo 
are  acquainted  wiih  the  special  researches  and  pub- 
lications of  the  respective  authors  will  not  fail  to 
notice  that  by  a  judicious  exerci>e  of  editorial  dis- 
cretion, each  subject  has  been  entrusted,  a^  far  as 
possible,  to  a  suigeon  of  the  hospitals  who  is  known 
to  have  given  especial  attention  to  it,  and  to  possess 
facilities  for  summing  up  with  authority  the  accepted 
opinions  of  the  day,  and  adding  original  matter  to 
the  stock. — London  Lancet. 

The  work  must  be  considered  a  very  complete  ac- 
count of  everything  connected  with  the  science  and 
practice  of  surgery,  la  conclusion  we  can  cordially 
recommend  this  work  as  a  valuable  addition  to  the 


library  of  the  surgeon. — Edinburgh  Hi edieal  Jour- 
nal. 

It  is  a  cyclopedia  of  surgery  of  the  most  complete 
and  extensive  character;  and  we  may  justly  state 
that  its  design  and  execution  do  great  honor  to  those 
concerned,  and  that  the  large  number  and  high 
standing  of  the  authors  selected  for  the  various 
monographs  render  this  "System"  what  it  no  doubt 
was  intended  to  be,  representative  of  the  actual  state 
of  surgical  science  and  art  in  the  country. — London 
Lancet. 

In  conclusion,  we  will  add  that  we  can  most  con- 
sciencionsly  recommend  the  book  to  every  medic, il 
practitioner.  In  recommending  the  "iSystonr^.S'U  ■ 
gery"  to  our  friends  who  have  to  deal  in  suigical 
cases,  we  by  no  means  wish  to  conliae  our  recom- 
mendation to  them  alone.  Every  practitiouei  of 
medicine  may  cull  something  worthy  of  note  from  a 
perusal  of  this  volume.—  The  Britis'i  M-id.  Journal. 

The  four  volumes  remain  a  monument  to  the  sur- 
gical genius  of  our  day.  The  great  majority  of  me- 
tropolitan surgeons  of  eminence  and  proved  ability 
are  represented  in  them  ;  and  for  many  years  to 
coine,  whoever  wishes  to  know  the  most  authori- 
tative words  of  English  Surgical  science  on  most 
subjects  in  the  domain  of  surgery,  must  turn  to  these 
pages  to  read  what  there  is  tec  forth,  but  taken  as 
a  whole  it  is  the  most  important  surgical  work  which 
has  ever  issued  from  the  Euglish  pie&s.— Loudon 
Lancet. 


28  He\ry  C.  Lea's  Son  &  Co.'s  Publications — (Surgery). 

-DRYANT  (THOMAS).  F.R.C.S., 

J-^  S'crgeon  to  Guy's  Hospital. 

THE  PRACTICE  OF  SURGERY.     Third  American,  from  the  Sec- 

ond  and  Revised  English  Edition.  Thoroughly  revised  and  much  improved,  by  John  B. 
Roberts,  M.D.  In  one  large  and  very  handsome  imperial  octavo  volame  of  over  1000 
pages,  with  672  illustrations.  Cloth,  $6  50  ;  leather,  $7  50  j  very  handsome  half  Russia, 
raised  bands,  $8  00.    {Just  Ready.) 

Jtr.  Bryant's  work  ha«  long  been  a  favorite  one  '  the  whole  work  has  been  carefully  revised,  ranch 
•with  snrgeoas.  As  its  n«me  indicates,  it  is  of  a  tho-  of  it  has  been  rewritten,  important  additions  have 
roughly  practical  character.  It  is  distinctly  indi-  een  made  to  almost  every  chapter. — Cincinnati 
vidaal  in  that  it  gives  ihe  results  of  the  author's  i  Med.  Setcn,  Jan.  l&Sl. 

large  and  varied  experience  as  an  operator  and  cli-  The  English  edition,  from  which  this  is  printed, 
nical  teacher,  aid  IS  on  that  account  prized  deserv-  has  been  carefullv  revised  and  rewritten;  almost 
edly  high  as  an  original  work.  The  .-tyle  is  neces-  g^g^y  chapter  his  received  additions,  atid  nearly 
sarily  condensed,  the  descriptions  of  surgical  dis-  ^^g  hundred  new  cuts  introduced.  The  labors  of 
eases  brief  and  to  the  point.  The  illustrations  are  the  American  editor,  Dr.  John  B.  Roberts,  have 
well  chosen,  and  the  typical  ca^es  of  the  author  s  ,  .y.g,y  ^^^^  increased  the  valne  of  the  book.  He 
experience  are  fall  of  Interest,  and  are  of  more  than  1,^^  introduced  manv  new  illustrations  and  much 
ordinary  value  to  the  working  surgeon.— JS.  Y.  ^g^  material  not  found  in  the  English  e.iitioa. 
Medical  Rteord,  March  5,  ISt-l.  i  Hg  has  written  too  with  great  conci^eness,  which 

It  is  a  work  especially  adapted  to  the  wants  of  is  a  rare  virtue  in  an  American  editor  of  an  Eiig":i-h 
students  and  practitioners.  While  not  prolix,  it  work.  If  one  could  procure  or  wished  only  one 
affjrds  instruction  in  i-nfficient  detail  for  a  full  un-  surgery,  ihis  volume  would  certainly  be  selected, 
derstanding  of  surgical  principles  and  the  treat- .  If  he  de>-ired  two,  Erich^en'6  Surgery  would  be 
ment  of  surgical  diseases  ltembrace>in  its  scope  '  added,  and  if  he  wished  a  third,  Gross's  Surgery 
all  the  diseases  that  are  recognized  as  belmgiug  to  '  would  justly  be  the  work  selected  A-  the  great 
surgery,  and  all  traumatic  injuries.  In  discus^inir  i  work  of  Gross  is  amply  snflBci^nt  for  the  waits  of 
these  it  has  seemed  to  be  the  aim  of  ihe  author  any  surgeon,  the  priority  given  to  Erieh«en,  and 
rather  to  present  the  student  with  practical  iiifor-  \  above  all  others,  to  this  work  of  Bryant,  is  no 
malion.  ard  that  alone,  than  toburdec  his  memory  labored  eulogy  of  the  last  volume,  but  a  simple  and 
with  the  views  of  different  writers,  however  dis  ja>t  statement  of  its  demonstrable  and  pre-eminent 
tinguished  they  might  have  been.     In  this  edition     merits. — Am.  Med.  Bi- Weekly,  Feb.  26,  1.S81. 

PRICHSEN  {JOHN  E.), 

-*-^  Profe,Heor  of  Surgery  in  tfnivergity  College,  London,  etc. 

THE  SCIENCE  AXD  ART  OF  SURGERY;  being  a  Treatise  on  Sur- 

gical  Injuries,  Diseases  and   Operations.       Carefully  revised   by  the  Author  from  the 
Seventh  and  enlarged  English  Edition.    Illustrated  by  eight  hundred  and  sixty-two  en- 
gravings on  wood.     In  two  large  and  beautiful  octavo  volumes  of  nearly  2000  pages  : 
cloth,  $8  50  :  leather,  $10  50;  half  Russia,  $11  50.     {Now  Ready.) 
Of  the  many  treatises  on  :?urgery  which  it  has  been        The  seventh  edition  is  before  the  world  asthe  last 
our  ta.sk  to  .*tudy.  or  our  pleasure  to  read,  there  is  none  I  word  of  surgical  science.  There  may  be  monographs 
which  in  all  points  has  satisfied  us  so  well  as  the  classic    which  excel  it  upon  certain  points,  but  as  a  con- 
treatise  of  Erichsen.    His  polished,  clear  style,  his  free-    spectns  upon  surgical  principles  and  practice  it  is 
dom  from  prejudice  and  bobbies,  his unsurpa.^ised  grasf  ;  unrivalled.     It   will  well  reward  practitioners   to 
of  his  subject,  and  vast  clinical  experience,  qualify  him  .read  it,  for  it  has  been  a  peculiar  province  of  Mr. 
admirably  to  write  a  model  text-book.    Whenwewish.  ■  Erichsen  to  demonstrate  the  absolute  interdepend- 
at  the  least  cost  of  time,  to  learn  the  most  of  a  topic  it     ence  of  medical  and   surgical  science      We   need 
surgery,  we  turn,  by  preference,  to  his  work.     It  is  a    scarcely  add,  in  conclusion,  that  we  heartily  corn- 
pleasure,  therefore,  to  see  that  the  appreciation  of  it  if    mend    the    work    to    students  that   they   may   be 
general,  and  has  led  to  the  appearance  of  another  edi  I  grounded  in  a  sound  faith,  and  to  practitioners  as 
tion. — Med.and  Surg.Repiirur.feh.'i,\&'&.  i  an  invaluable  guide  at  the  bed^ide. — Am    Praeti- 

Xotwithstaniliog  the  increase  in  size,  weobserve  that  i  tioner,  April,  IS/S. 
much  oM  matter  has  been  omitted.  The  entire  work  ;  For  the  past  twenty  years  Erichsen'a  Surgery  has 
has  been  thoroughly  written  up,  and  not  merely  amend-  maintained  its  place  as  the  leading  text-book,  not  only 
ed  by  a  few  extra  chapters.  A  great  improvement  ha^  I  in  this  country,  but  in  Great  Britain.  That'll  is  able 
been  made  in  the  illustrations.  One  hundred  and  fifty  i  to  hold  its  ground,  is  abundantly  proven  by  the  tho- 
new  ones  have  been  added,  and  many  of  the  old  onet  \  roughness  with  which  the  present  editionhas  been 
have  been  redrawn^  The  author  highly  appreciates  the  revised,  and  by  the  large  amount  of  valuable  mate- 
favor  with  which  his  work  has  been  received  by  Ameri-  rial  tha;  has  been  added.  Aside  from  this,  c  ne  bun- 
can  surgeons,  and  has  endeavored  to  render  his  latest  dred  and  fifty  new  illnstra-.ions  have  been  inserted 
edition  more  than  ever  worthy  of  their  approval.  That  including  quite  a  number  of  microscopical  appear- 
he  has  succeeded  admirably,  must,  we  think,  be  the  inces  of  pathological  processes,  io  marked  is  this 
general  opinion.  We  heartily  recommend  the  book  tc  change  for  the  better,  that  the  work  almost  appears 
both  student  and  practitioner. — ^V.  T.Med.  Journal.  I  as  an  entirely  new  one. — Med.  Record,  Feb  23  1878 
Feb.  1878.  I  •      ,         . 


TIOLMES  (TIMOTHY).  M.D. , 

J--*-  Surgeon  to  St.  Oeorge's  Hosjjital,  London. 

SURGERY,  ITS  PRINCIPLES  AXD  PRACTICE.  In  one  hand- 
some octavo  volume  of  nearly  lOUO  pages,  with  411  illustrations.  Cloth,  $6;  leather  =^7  • 
half  Russia,  $7  50.  '  *    ' 

This  is  a  work  which  has  been  lookedfor  on  both  f  its  force  and  distinctness.— A^.  T.  Jfed  Record  Anril 
sides  ofthe  Atlantic  with  much  interest.  Mr.  Holmes    14,  1876.  ' 

is  a  surgeon  of  large  and  varied  experience,  and  one        t.„:iiv,«c j  „„     .  i,      ^ 

of  the  best  known,  and  perhaps  the  most  brilliant        ^'  ^^^^X  ,         '  ^^.^eUent  epitome  of  snr- 

writer  upon  surgical  subjects  in  England      It  is  a  i  f"''  .''^'^^  general  practmoner  who  ha.s  not  the 
book  for  studentl-and  an  admirablf  one-and    or    'l'^X\''fl^^'T'"'V''  ^"J^^'^^)^  f^^  extended 


ipairea    larworkin  the  profession,  and  especially  as  a  text- 
I  book, — Cincinnati  Med.  Ifetos,  April,  1876, 


Henry  C.  Lea's  Son  &  Co.'s  Publications— (OpAfAaZwio^y).      29 
JT/'ELLS  (J.  SOELBEEG),  ~ 

'  r  Professor  of  Ophthalmology  in  King's  College  Hospital  &c 

A  TREATISE  ON    DISEASES  OF  THE  EYE.     Third  American 

from  the  Third  London  Edition.  Thoroughly  revised,  with  copious  additions  by  Chas' 
S.  Bull.M  D.,  Surgeon  and  Pathologist  to  the  New  York  Eye  and  Ear  Infirmary.  Illus- 
tratedwith  about  260  engravings  on  wood,  and  six  colored  plates  Together  with  sele'^- 
tions  from  the  Test-types  of  Jaeger  and  Snellen.  In  one  large  and  very  handsome 
octavo  volume  of  900  pages.  Cloth,  §5  ;  leather,  $6  ;  half  Russia,  raised  bands,  $6  50. 
{Just  Ready. ) 

The  long-continued  illness  of  the  author,  with  its  fat.nl  termination,  has  kept  this  work  for 
some  time  out  of  print,  and  has  deprived  it  of  the  advantage  of  the  revi.-ion  which  he  sought 
to  give  it  during  the  last  years  of  hi?  life.  This  edition  ha^s  therefore  been  pla-ed  under  the 
editorial  supervision  of  Dr.  Bull,  who  has  labored  earnestly  to  introduce  in  it  all  the  advances 
which  observation  and  experience  have  acquired  for  the  theory  and  practice  of  ophthalmology 
since  the  appearance  of  the  last  revision.  To  accomplish  thi.s  considerable  additions  have  been 
required,  and  the  work  is  now  presented  in  the  confidence  that  it  will  fully  deserve  a  continu- 
ance of  the  very  marked  favor  with  which  it  has  hitherto  been  greeted  as  a  complete,  but  con- 
cise, exposition  of  the  principles  and  facts  of  its  important  department  of  medical  science. 

The  additions  made  in  the  previous  American  editions  by  Dr.  Hays  have  been  retained, 
including  the  very  full  series  of  illustrations  and  the  test-types  of  Jaeger  and  Snellen. 

This  new  edition  of  Dr.  Wells's  great  wui-k  on  ihe    guage.     In  tbe  becond  edi;ioii,   the  author  showed 


eye  will  be  welcomed  by  the  profession  at  large  a 
well  as  by  the  oculist.  It  contain  s  much  new  m'tter 
relating  to  treatment  and  pathology,  and  i.-s  brought 
thoroughly  up  with  the  pre-ent  ttatus  of  ophthal- 
mjlogy.  Its  chapter  on  refraction  and  accommo- 
datiou — a  subject  much  discussed  of  late  years,  and 
of  great  importance — is  exceedingly  complete. — 
Louisville  3Ied.  Ntws,  Nov.  13,  ISSO. 

The  merits  of  Wells's  treatise  on  diseases  of  the 
eye  have  been  so  universally  acknowledged,  and  are 
so  familiar  to  all  who  profess  to  have  given  any  at- 
tention to  ophthalmic  surgery,  that  any  discussion 
of  them  at  this  laie  day  will  be  a  work  of  superero- 
gation. Very  little  that  is  practically  useful  in  re- 
ceat  ophthalmic  literature  has  escaped  the  editor, 
and  the  third  American  edition  is  well  up  to  the 
times.  As  a  text-book  on  oph.halmic  surgery  for  the 
English-speaking  practitioner,  it  is  without  a  rival. 
— Am.  Journ.  of  Med.  Sci.,  Jan.  18S1. 

The  work  has  justly  held  a  high  place  in  English 
ophthalmic  literature,  and  at  the  time  of  its  first  ap- 
pearance was  the  best  treatise  of  its  kind  ia  the  lan- 


industriott.-i  research  in  adding  new  material  from 
every  quarter,  and  his  spirit  was  eminently  candid. 
A  work  thus  baill  up  by  honest  effort  should  not  be 
suffered  to  die,  and  we  are  pleased  to  receive  this 
third  edition  from  the  hands  of  Dr.  Bull.  His  labor 
hxs  been  arduous,  as  the  very  great  number  of  addi- 
tions bracketeu  with  his  initial  testify.  Under 
the  editorship  which  the  third  edition  has  enjoyed, 
the  work  is  sure  to  sustain  its  good  reputation,  and 
to  maintain  its  usefulness. — N.  ¥.  Mea.  Journ.,  Jan. 
18S1. 

There  is  really  no  work  which  approaches  it  in 
adaptation  to  the  wants  of  the  general  practitioner, 
while  the  most  advanced  specialist  cannot  rise  from 
a  peni.^al  of  its  ample  pages  without  having  added 
to  his  knowledge.  The  American  editor,  Dr.  Bull, 
won  his  spurs  in  ophthalmology  some  time  back. 
Hii?  additions  lo  the  woik  of  the  lamented  Wells  are 
many,  judicious,  and  timely,  and  in  just  so  much 
have  added  to  its  value.— J.r/i.  F ractitioner ,  Jan. 
IsSl. 


fJETTLESHIP  {EDWARD),  F.B.G.S., 

-^  '  ophthalmic  Surg,  and  Led.  on  Ophth.  Surg,  at  St.  Thomas'  Hospital,  London. 

MANUAL    OF    OPHTHALMIC    MEDICINE.     In  one  royal  12mo. 

volume  of  over  350  pages,  with  89  illustrations.     Cloth,  $2.     (Just  Ready.) 
The  author  is  to  be  congratulated  upou  the  very  ,  information  they   contain.     We  do   not   hesitate   to 
ful  manner  in  which  he  has  accomplished  his  :  pronounce  Mr.  Nettleship's  book  the  best  manual  on 

ophlhalraic   turgery   for   ihe   use   of   students   and 


succe 

task;  he  has  succeeded  iu  being  concise  without 
sacrificing  clearnes.-j,  and,  including  the  whole 
ground  covered  by  more  voluminous  text-books, 
has  given  an  excellent  risumi  of  all  the  practical 


"  busy  practitioners"  with  which  we  are  acquain- 
ted. —Am.  Jour.  Med.  Sciences,  April,  1880. 


c- 


fARTER  [R.  BRUDENELL),  F.R.G.S., 

ophthalmic  Surgeon  to  St.  George' s  Hospital,  etc. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  EYE. 


Edit- 


ed, with  test-types  and  Additions,  by  John  Green,  M.D.  (of  St.  Louis,  Mo.).  In  one 
handsome  octavo  volume  of  about  500  pages,  and  124  illustrations.  Cloth,  $.3  75. 
It  is  with  great  pleasure  ihaiwecanendorse  the  work  i  chapter  is  devoted  to  a  discus:?iou  oi  the  uses  andselec- 
as  a  most  valuable  contribution  to  practical  ophthal- 1  tion  ofspectacles,  and  is  admirably  compact,  plain,  and 
raology.  Mr.  Carter  never  deviates  from  the  end  he  has  ;  useful,  especially  the  paragraphs  on  the  treatment  of 
in  view,  and  presents  the  subjectin  a  clear  and  concist  ]  pre.'ibyopia  and  myopia.  In  conclusion,  our  thanks  are 
manner,  easy  of  comprehension,  and  hence  the  more  |  due  the  author  for  many  useful  hintsin  the  great  sub- 
valuable.  We  would  especially  commend,  however,  asject  of  ophthalmic  surgery  and  therapeutics,  afield 
worthy  of  high  praise,  the  manner  iu  which  the  thera-  j  where  of  late  years  we  glean  but  a  few  grains  of  sound 
peutics  of  disease  of  the  eje  is  elaborated,  for  here  the  i  wheat  from  a  mass  of  chaff. — New  York  Medical  Record, 
author  is  particularly  clear  and  practical,  where  other  Oct.  23, 1875. 
writ-ers  are  unfortunately  too  often  deficient.  The  final  I 

ROWNE  {EDGAR  A.),  " 

Surgeonto  the  Liverpool  Eye  and  'Ear  Infirmary ,  and  tothe  Dispensary  for  SMn  Diseases. 

HOW  TO  USE  THE  OPHTHALMOSCOPE.     Being  Elementary  In- 

structions  in  Ophthalmoscopy,  arranged  for  the  Use  of  Students.    With  thirty-five  illustra- 
tions.    In  one  small  volume  royal  12mo.  of  120  pages  :  cloth,  $1. 


B 


LAURENCE'S    HANDST-BOOK    OF    OPHTHALMIC 

SORGERT,  for  the  uoe  of  Practitioners.  Second 
edition,  revised  and  enlarged  With  numerous 
illustrations.  In  one  very  handsome  octavo  vol- 
»nie,  cloth,  $2  75. 


LAWSON'S  INJURIES  TO  THE  EYE,  ORBIT 
AND  EYELIDS:  their  Immediate  and  Remjte 
Effects.  With  about  one  hundred  illustrations. 
In  one  very  handsome  octavo  volume,  cloth, 
*3  50. 


30    Henry  C.  Lea's  Son  &  Co.'s  Publications — (Med.  Jurisprudence). 
jyURNETT  [CHARLES  H.),  M.A  ,  M.D., 

J-^  Aurj.!  Surg  to  the  Presb.  Hosp.,  Surgeoii'in-charge  of  the  Infir.  for  Vis .  of  the  Ear,  Phila. 

THE    EAR,  ITS    ANATOMY,   PHYSIOLOGY  AND     DISEASES. 

A  Practical  Treatise  for  the  Use  of  Medical  Students  and  Practitioners.     In  one  hand- 
some octavo  volume  of  6  1  5  pages,  with  eighty-seven  illustrations  :  cloth,  $4  50  j  leather, 
$5  60;  half  Russia,  $6  00.      {Lately  Issued.) 
ForemoPt  among  the   numerons  receut  coutrihu-  i  ttie  observations  and  discoveries  of  others,  has  pro- 
tioQs  to  aural  literaturt  will  be  ranked   this  work  j  duced  a  work  which,  as  a  text-book,  stands /«cf/e 
of  Dr.  Burnett.     It   is  impossible  to    do  ju.-'tic"    lo  ,  priyicpti  in  our  lanijuage.     We  had  marked  several 


this  volume  of  over  600  pages  in  a  nece.-'ariiy  bii(?f 
notice.  It  must  safflce  to  add  ihat  the  book  is  pro- 
fusely and  accurately  illusirated,  the  references  are 
conscientiously  acknowledged,  while  the  result  liar, 
been  to  produce  a  treati^e  which  will  hencefoiib 
rank  with  the  classic  writings  of  Wilde  and  Von 
Troltsch.  —  The  Lond.  Practiliiiner,  May,  1879. 

On  account  of  the  great  advances  which  have  been 
made  of  late  years  in  otology,  and  of  the  increased 
interest  manifested  in  it,  the  medical  profession  will 
welcome  this  new  work,  which  presents  clearly  and 
concisely  its  present  aspect,  whilst  clearly  indi- 
cating the  direction  in  which  further  researches  can 
be  most  profitably  carried  on.  Dr.  Barn-tt  from  his 
own   matured  experience,  and  availing  himself  of 


pa  sages  as  well  worthy  of  quotation  and  the  atten- 
tion of  the  general  practitioner,  lint  their  number  and 
the  space  at  on r  command  forbid.  Perhaps  ii  is  bet- 
ter, as  th«  book  ought  to  be  in  the  hands  of  every 
medical  studeut,  and  its  study  will  well  rejiay  tl?e 
busy  practitioner  in  the  pleasure  he  will  derive  from 
the  agreeable  style  in  which  many  otherwise  dry 
and  luosily  anknown  sulijecis  are  treated.  To  the 
specialist  tlie  work  is  of  the  highest  value,  and  his 
sense  of  graiilude  to  Dr.  Burnett  will  we  hope,  be 
proportionate  to  the  amount  of  benefit  lie  can  obtain 
from  the  carelul  study  of  the  book,  and  a  constant 
reference  to  its  trustworthy  pages. — Edinburgh 
Med.  Jour.,  Aug.  1878. 


q^AYLOR  [ALFRED    S.),M.D., 

J.  Lecturer  on  Med.  Jurisp.  and  Ghemiatry  in  Ouy's  Hospital. 

A  MANUAL  OF   MEDICAL  JURISPRUDENCE.     Eighth  Ameri- 

can  edition.    Thoroughly  revised  and  rewritten.     Edited  by  Johw  J.  Reese,  M.D.,  Prcf. 

of  Med.  Jurisp.  and  Toxicology  in  the  Univ.  of  Penn.      In  one  large  octavo  volume  of 

933  pages,  with  70  illostrations.     Cloth,  $5;   leather,  $6;    half  Russia,  raised  bands. 

$6  50.  {Just  Ready.) 
The  American  editions  of  this  standard  manual  (  is  to  announce,  not  criticize  the  completed  task.  The 
have  for  a  Ion,'  time  laid  claim  to  the  attention  of  !  value  of  the  getn  is  too  well  known  to  require  more 
the  profession  in  this  country  ;  and  that  the  profes-  [  than  the  telling  'ihat  the  mtster-hand  has  rebrigh^- 
Kion  ha"  recognized  this  claim  with  favor  is  proven  \  ened  its  facets  aod  polished  its  angles  before  leaving 
by  the  call  for  frequent  new  editions  of  the  work.  |  it  as  his  legacy  to  h's  brethren  in  the  profession.— 
This  one,  the  eighth,  comes  before  us  as  embodying     Phila   M-:d.  Tims,  Dec.  4,  1880. 


the  latest  thoughts  and  emendations  of  Dr.  Taylor, 
upon  the  subject  to  which  he  devo  ed  hirt  life,  with 
an  assiduity  aud  success  which  made  him  facile 
prinreps  among  English  writers  on  medical  juris- 
prudence. Both  the  author  and  the  book  have 
mdde  a  mark  too  deep  to  be  affected  by  criticism, 
whether  it  be  censure  or  praise.  In  this  case,  how- 
ever, we  should  only  have  to  seek  for  laudatory 
teims. — Am.  Jnurn.  of  Med.  Sci.,  Jan.  ISSl. 

It  is  not  very  often  that  a  m-idical  book  reaches  its 
tenth  edition,  or  that  the  last  earthly  labor  is  per- 
formed by  the  author  in  reioucluag  the  work  that 
llrst  came  from  his  hand  thirty-five  years  before. 
All  this,  however,  has  h.ippened  ia  the  ca>e  of  Dr. 
Taylor  and  his  classical  treatise.  The  pen  dropped 
from  the  grasp  only  when  the  shadows  of  old  age 
were  rapidly  deepening  into  the  darkness  of  death. 
Under  the  circamstances,  all  the  journalist  has  to  do 


It  will  suffice  to  remarit  that  this  new  edition 
shows  the  signs  of  judicious  revision.  A  great  uum- 
ber  of  illustrative  medico- legal  cases  which  have 
occurred  since  the  last  edition  was  puhlished  are 
cited  in  heir  proper  connection,  and  add  luach  to 
the  interest  and  value  of  the  work;  they  comprise 
the  buls  of  the  additions  to  the  text.  As  an  iodica.- 
tionofthe  reshuesiof  the  work,  we  notice  n'jmer- 
ous  references  to  medic  i-legal  experience  that  has 
transpired  during  the  year  just  ended  ;  among  tbes-e 
is  a  comment  by  the  American  editor  upon  that 
midsummer  madness,  the  T.inner  fasting  exploit  of 
last  Augist.  la  these  features  and  in  others  there 
is  ample  evidence  that  this  admirable  book  will 
maintain  its  hi^h  place  as  a  standard  authority  con- 
cerning thf  matters  of  which  it  ire-Ais. —Jiuston 
Mad.  and  Sarg.  Journal,  Jan.  13,  1881. 


f>Y  THE  SAME  AUTHOR. 

THE  PRINCIPLES  AND  PRACTICE  OF  MEDICAL  JURISPRU- 

DENCE.     Second  Edition,  Revised,  with  numerous  Illustrations.    In  two  large  octavo 
volumes,  cloth,  $10  00  ;  leather,  $12  00 
This  great  work  is  now  recognized  in  England  as  the  fullest  and  most  authoritative  treatise  on 
everv  departmentof  its  important  subject.  In  laying  it,  in  its  improved  form,  beforethe  Amer- 
ican profession,  the  publishers  trust  that  it  will  assume  the  same  position  in  this  country. 

T>T  THE  SAME  AUTHOR. 

POISONS  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND 

MEDICINE.     Third  American,  from  the  Third  and  Revised  English  Edition.     In  one 
large  octavo  volume  of  850  pages  ;  cloth,  $5  50  ;  leather,  $6  60. 
The  present  is  based  upon  the  two  previous  edi-  ,  being  described  which  give  rise  to  legal  investiga- 
tions; ''bulthecompleterevision  rendered  necessary    tions.  —  The  Olinic,  Wo  v.  6,  187.'5. 


by  time  has  converted  it  into  a  new  work."  This 
statement  from  the  preface  contains  all  that  it  is  de- 
sired to  know  in  reference  to  the  new  edition  The 
works  of  this  author  are  already  in  the  library  of 
every  physician  who  is  liable  to  be  called  upon  for 
medico-legal  testimony  (and  whatuneis  not?),  so  that 
all  that  Is  required  to  be  known  about  the  present 
book  is  that  the  author  has  kept  it  abreast  with  the 


Dr.  Taylor  hat  brought  to  bear  on  the  compilation 
of  this  volume,  stores  of  learning,  experience,  and 
practicalacquaiutanee  with  his  subject,  probably  tar 
beyond  what  any  other  living  authority  on  toxicol- 
ogy could  have  amassed  or  utilized.  He  has  fully 
sustained  his  reputation  by  the  consummate  skill 
and  legal  acumen  he  has  displayed  in  thearrange- 
,  .   ,,     ,  ment  of  tne  subject-matter,  and  the  result  is  a  work 

times.  What  makes  it  now,  as  always,  especially  i  qq  Poisons  which  wiUbeindispensable  to  every  siu- 
valuable  to  the  practitioner  is  its  conciseness  and  dentor  practitioner  in  lawand  medicine.— r/j«Z>ti6. 
practical  character,  only  those  poisonous  substances  |  ;„^  Journ.  of  Med  Sex.,  Oct.  1875. 


Henkt  C.  Lea's  Son  &  Co.'s  PrBLicATiONS — (Miscellaneous).       31 


J^OBERTS  [WILLIAM),  M.D., 

-*■*'  Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  etc. 

A  PRACTICAL  TREATISE  ON  URIXARY  AND  RENAL  DIS- 
EASES,includingUrinary  Deposits.  Illustrated  by  numerons  cases  and  engravings.  Third 
American,  from  the  Third  Revised  and  Enlarged  London  Edition.  In  one  largt  and 
handsome  octavo  volume  of  over  600  pages.     Cloth,  $4.     (Just  Ready.) 

rr HO  MP  SON  [SIR  HENRY), 

•^  Surgeon  and  Professor  of  Clinical  Surgery  to  University  College  Hospital . 

LECTURES  ON  DISEASES  OF  THE  URINARY  ORGANS.  With 

illustrations  on  wood.     Second  American  from  the  Third  English  Edition.    In  one  neat 
octavo  volume.     Cloth,  $2  25. 
J>T  THE  SAME  AUTHOR.  

ON  THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OF 

THE  URETHKA  AND  URINARY  FISTULA.    With  plates  and  wood-cuts.     From  the 
third  and  revised  English  edition.    In  one  very  handsome  octavo  volume,  cloth,  %'6  5U. 

rrUKE  [DANIEL  HACK),  M.D., 

J-  Joint  author  of  The  Manual  of  Psychological  Medicine,  &o. 

ILLUSTRATIONS  OF  THE  INFLUENCE  OF  THE  MIND  UPON 

THE  BODY  IN  HEALTH  AND  DISEASE.      Designed  to  illustrate  the  Action  of  the 
Imagination.     In  one  handsome  octavo  volume  of  416  pages,  cloth,  $3  25. 

-DLANDFORD  [G.  FIELDING),  M.D.,  F.R.G.P., 

J-^  Lecturer  on  Psychological  Medicine  atthe  School  of  St.  George's  Hospital,  &e. 

INSANITY  AND  ITS  TREATMENT:  Lectures  on  the  Treatment, 

Medical  and  Legal,  of  Insane  Patients.     With  a  Summary  of  the  Laws  in  force  in  the 

United  States  on  the  Confinement  of  the  Insane.     By  Isaac  Ray,  M.  D.    In  one  very 

handsome  octavo  volume  of  471  pages  ;  cloth,  $3  25. 

It  satisfies  a  want  which  mnsl  have  been  sorely    actually  seen  in  practice  and  the  appropriate  treat- 

feltby  the  basygeneralpractitionersof  thibconntry.    ment  for  them,  we  find  in  Dr.  Blandford's  work  a 

It  takes  the  form  ofa  manual  ofclinicaldescription    considerable  advanceover  previous  writings  on  the 

of  the  various  forms  of  insanity,  with  a  description  ■  subject.  His  pictures  of  the  various  forms  ofmental 

of  the  mode  of  examining  persons  suspected  of  in-  i  disease  are  so  clear  and  goodthat  no  readercan  fail 

si-aity.    We  call  particular  attention  to  this  feature  ,  to  be  struck  with  their  superiority  to  those  given  in 

of  the  book,  as  giving  it  a  unique  valneto  the  gene-    ndinary  manuals  in  the  English  language  or  (so  far 

f  al  practitioner.  If  we  pass  from  theoretical  conside-j  as  our  own  reading  extends;!  n  any  other. — London 

rations  to  descriptionsof  the  varieties  of  insanity  as  |  Practitioner,  Feb.  1871. 


f  EA  [HENRY  C). 

SUPERSTITION   AND   FORCE :    ESSAYS   ON  THE   WAGER   OF 

LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL  AND  TORTURE.      Third  Revised 

and   Enlarged  Edition.    In  one  handsome  royal  12mo.  volume  of  552  pages.     Cloth, 

$2  50.      [Just  Ready.) 

This  valuable  work  is  in  reality  a  history  of  civi-  .  more  accurate  than  either  of  the  preceding,  but, 

lization  as  interpreted  by  the  progress  of  jurispru-'  from  the  thorough  elaboration,  is  more  like  a  har- 

dence.  ...     In  "  Sapei'stition  and  Force"  we  have    monious  concert  and  less  like  a  batch  of  studies.— 

a  pnilosophic  survey  of  the  long  period  intervening     The  Nation,  Aug.  1,  1S7S. 

between  primitive  barbarity  and  civilized  enlight-  jiany  will  be  tempted  to  say  that  this,  like  the 
euuient.  There  is  not  a  chapter  in  the  work  that  ..X)eclineandFall."-isone  of  the  uncriticizable  books, 
should  not  be  most  carefully  studied,  and  however  ,  its  facts  are  innumerable,  its  deductions  simple  and 
well  versed  the  reader  may  be  in  the  science  of  ^  inevitable,  and  its  chevav^de-frise  of  references 
jui-isprud.-nce,  he  will  find  much  in  Mr.  Lea's  vol-  bristlingand  dense  enough  to  make  the  keenest, 
ume  of  which  he  was  previously  ignorant.  The  stoutest,  and  best  equipped  assailant  think  twice 
b.jok  is  a  valuable  addition  to  the  literature  of  before  advancing.  Xor  is  there  anything  contro- 
soc\d,\i<:\eaQe.— Westminster  Review,  39,a.  ma.  versialinit  to  provoke  assault.    The  author  is  no 

The  appearance  of  a  new  edition  of  Mr.  Henry  C.  '  polemic.  Though  he  obviously  feels  and  thinks 
Lea's  "Saperstition  and  Force"  is  a  sign  that  our  strongly,  he  succeeds  in  attaining  impartialify. 
highest  scholarship  is  not  without  honor  in  its  na  Whetl  er  looked  on  as  a  picture  or  a  mirror,  a  work 
ti/e  country.  Mr.  Lea  has  met  every  fresh  demand  such  as  this  has  a  lasting  valae. — LippineotVs 
for  hrs  work  with  a  careful  revision  of  it,  and  the  Magazine,  Oct.  1S7S. 
present  ecition  is  not  only  fuller  and,  if  possible. 


JJY  THE  SAME  AUTHOR. 

STUDIES  IN  CHURCH  HISTORY.    THE  RISE  OF  THE  TEM- 

PORAL  POWER— BENEFIT  OF    CLERGY— EXCOMMUNICATION.     In   one   large 
royal  12mo.  volume  of  516  pp.;  cloth,  $2   75.     {Lately  Published.) 

The  story  was  never  told  more  calmly  or  with  las  apecuIiarimportancefortheEnglishstudent.and 
greater  learning  or  wiser  thought.  We  doubt,  indeed,  is  a  chapter  on  Ancient  Law  likely  to  be  regarded  as 
If  any  other  study  of  this  field  can  be  compared  with  flual.  We  can  hardly  pass  from  our  mention  of  such 
this  for  clearness,  accuracy,  aad  power.  —  Chicago  works  as  these — with  which  that  on  "Sacerdotal 
Brraminer,  Dec.  1S70.  Celibjcv' "  should  be  included— withoat  notin?  tt  e 

Mr.  Lea's  latest  work, -'Studiesin Church  History," 
fully  sustains  the  promise  of  the  first.  It  deals  with 
three  subjects — the  Temporal  Power,  Benefit  of 
Clergy,  and  Excommunication,  the  record  of  which  \ 


32 


Henry  C.  Lea's  Son  &  Co.'s  Publications. 


INDEX   TO    CATALOGUE. 


American  Joarnalof  the  Medical  Sciences 

Allen's  Anatomy    ..... 

Anatomical  Atlas,  by  Smith  and  Horner 

A.shton  on  the  Kectum  and  Anus 

Atttield's  Chemistry    .... 

Ashwell  on  Di.seases  of  Females 

*ishhurst'g  Surgery      .... 

Browne  on  Ophthalmoscope  .        .        , 

Browne  on  the  Throat     . 

♦Burnett  on  the  Ear 

*Barne8  on  Diseases  of  Women    . 

Barnes'  Midwifery  .... 

Bellamy's  Surgical  Anatomy 

♦Bryant's Practice  of  Surgery    . 

Bloxam'sChemistry     .... 

Blandford  on  Insanity  . 

Basham  on  Renal  Diseases  . 

Bartholow  on  Electricity 

Barlows  Practice  ot  Medicine    . 

Bowman's  (John  E.)  Practical  Chemistry 

*Bristowe'&  Practice       .... 

*Bumsiead  on  Venerea] 

Biimslead  and  CuUerier's  Atlasof  Venereal 

♦Carpenter's  Human  Physiology 

Carpenter  on  the  Dae  and  Abuse  of  Alcoh 

♦Corniland  Kauvier 

Carter  on  the  Eye  . 

Clelaud's  Dissector 

Classen's  Chemistry 

Clowes'  Chemistry 

Coleman's  Dental  Surgery     . 

Century  of  American  aleuicine 

Chadwick  on  Diseases  of  Women 

Chambers  on  Diet  and  Eegiuien 

Christisonand  Griffith's  Dispensatory 

Churchill  on  Puerperal  Fever 

Condie  on  Diseases  of  Children  . 

Cooper's  (B.  B.)  Lectures  on  Surgery 

CuUerier's  Atlas  of  Venereal  Disease 

Duncan  on  Diseases  of  Women    . 

♦Dalton's  Human  Physiology 

Davis's  Clinical  Lectures 

Uewees  on  Diseases  of  Females  . 

Druitt's  ModernSurgery 

*Dunglison's  Medical  Dictionary 

Edis  on  Diseases  of  Women  . 

Ellis's  Demonstrations  in  Anatomy 

♦Erichsen's  System  of  Surgery 

♦Emmet  on  Diseases  of  Wouea 

Farquharson's  Therapeutics 

Foster's  Physiology  .     . 

Fenwicb's  Diagnosis      . 

Finlayson's  Clinical  Diagnosis 

Plint  on  Respiratory  Organs 

Flint  on  the  Heart 

*  •'lint's  Practice  of  Medicine. 
Flint's  Essays 
♦Flint's  Clinical  Medicine     . 
Flint  on  Phthisis    . 
Flint  on  Percussion 
*Fothergiirs  Handbook  of  Treatmeu 
Fdwnes's  Elementary  Chemistry 
Fox  on  Diseases  of  the  Skin 
Fuller  on    the  Lungs,  &c. 
Green's  Pathology  and  Morbid  Anato 
Greene's  Medical  Chemistry 
Gibson's  Surgery  .... 
Gluge's  Pathological  Histology,  by  L 
♦Gray's  Anatomy,. 
Galloway's  Analysis 
Griffith's  (R.  E.)  Universal  Formular; 
Gross  ou  Sterility    .... 
Gross  on  Urinary  Organs 
Gross  on  Foreign  Bodies  in  Air-Passag 
♦Cross's  System  of  Surgery 
Habershon  on  the  Abdomen  . 

*  Hamilton  on  Dislocations  and  Fractii 
Hartsliorne'a  Essentials  of  Medicine 
Harts  Home's  Conspectus  of  the  Medic 
Hartshorne's  Anatomy  and  Physiology 
Hamilton  on  Nervous  Diseases 
Hoffman's  Chemical  Analysis 
Henth's  Practical  Anatomy 
Hohlyn's  Medical  Dictionary 
Hodge  on  Women 
Hodge's  Obstetrics 


idy 


1  Sci 


PAOK 
.         1 

7 

7 

.     26 


Holland's  Medical  Notes  and  Reflections 

♦Holmes'  System  of  Surgery 

♦Holmes's  Surgery 

Holdon's  Landmarks 

Horner's  Anatomy  and  Histology 

Hudson  on  Fever   .... 

Hill  on  Venereal  Diseases    . 

Hillier's  Handbook  of  Skin  Diseases 

Jones  (C.  Handfieid)  on  Nervous  Disorders 

Knapp's  Chemical  Technology   . 

Keating  on  lufauls 

Lea's  Superstition  and  Force      .         . 
Lea's  Studies  in  Church  History 

Lee  on  Syphilis 

♦Leishman's  Midwifery         .... 

La  Roche  on  Yellow  Fever. 

La  Roche  on  Pneumonia,  kc. 

Laurence  and  Moon's  Ophthalmic  Surgery 

Lawson  on  the  Eye       ...  .        . 

Lehmann's  Physiological  Chemistry,  2  vols. 

Lehmann's  Chemical  Physiology 

Ludlow's  Manual  of  Examinations    . 

Lyons  on  Fever     ..... 

Maisch's  Materia  Medica 

Jliichell's  Nervous  Diseases  of  Women 

Medical  News  and  Abstract 

Morris  on  Skin  Diseases 

Meigs  on  Puerperal  Fever    . 

Miller's  Practice  of  Surgery 

Miller's  Principles  of  Surgery     . 

Montgomery  on  Pregnancy 

Nettleship's  Ophthalmic  Medicine 

Neill  and  Smith's  Compendium  of  Med  Scienc 

Parvia's  Midwifery        .... 

Parry  on  Extra-Uterine  Pregnancy 

Pavy  on  Digestion 

♦Parrish's  Practical  Pharmacy    . 

Pirrie's  System  of  Surgery  .         .        . 

♦Playfair's  Midwifery  .... 

Quain  and  Sharpey's  Anatomy,  by  Leidy 

♦Reynolds'  System  of  Medicine  . 

Richardson's  Preventive  Medicine 

Robertson  Urinary  Disea.ses 

Ramsbotham  on  Parturition 

Remsen'a  Principles  of  Chemistry 

Rigby's  Midwifery         .... 

Rodwell's  Dictionary  of  Science  . 

Stimson's  Operative  Surgery 

Swayne  s  Obstetric  Aphorisms    . 

Seller  on  the  Throat 

Sargent's  Minor  Surgery 

Sbarpey  and  Quain's  Anatomy,  by  Leidy 

Skey's  Operative  Surgery     . 

Slade  on  Diphtheria      .... 

SchSfer's  Histology        .... 

*Smith  (J- L.)  on  Children     . 

Smith  {ri.  H.)  and  Horner's  Anatomical  Atlas 

Smith  (Edward)  on  Consumption 

Smith  (East  )  on  Wasting  Di-seases  in  Children 

♦.•^'llll^'s  Therapeutics    .... 

♦Stille  &  Maisch's  Dispensatory  . 

Starges  on  Clinical  Medicine 

Stokes  on  Fever 

Tanner's  Manual  of  Clinical  Medicine 
Tanner  on  Pregnancy    . 
♦Taylor's  Medical  Jurisprudence 
Taylor's  Principles  and  Practice  of  Med   J 


6 

.  9 

.  11 

.  20 

.  26 

.  26 

.  26 

.  14 

.  2.) 

.  16 
ces   6 

.  7 

.  18 

.  11 

.  6 

.  4 

.  22 

.  24 


14  I  Taylor  on  Poisons 


Tnke  on  the  Infiueuce  of  the  Mind 

♦Thomas  on  Diseases  of  Females 

Thompson  on  Urinary  Organs 

Thompson  on  Stricture  .... 

Todd  on  Acute  Diseases 

Woodbury's  Practice     .... 

Walshe  on  the  Heart    .... 

Watson's  Practice  of  Physic 

♦Wells  on  the  Eye         .... 

West  on  Diseases  of  Females 

Weston  Diseases  of  Children 

West  on  Nervous  Disorders  of  Children 

Williams  on  Consumption    . 

Wilson's  Human  Anatomy  . 

Wilson's  Handbook  of  Cotaneons  Medicin 

Wiihler's  Organic  Chemistry 

Winckel  on  Childbed    .... 


nrisp 


A«B 

14 
27 
28 
6 
7 
20 
20 
19 
19 
10 
21 
31 
31 
20 
24 
14 
20 
29 
29 


6 
20 

'3 
18 

2 
19 
•^1 
25 
25 
21 
29 

5 
24 
23 
14 
11 
2-5 
24 

7 
17 
16 
31 
23 

9 
21 

4 
26 
21 
19 
26 

7 
26 
16 

7 
21 

7 
16 
20 
13 
12 
15 
14 

6 
23 
30 
80 
HO 
31 


31 
14 

16 
16 
16 
29 
21 
21 
21 
16 
7 
20 


Books  marked  *  are  also  bound  in  half  Russia. 


HENRY  C.  LEA'S  SOW  &  CO.— Philadelphia. 


DATE  DUE 


'S^^^^^oJ^o.  38-293 


^lll«ffi'iftin^'^^''SITY  LIBRARIES 


0043061095 


RC341 

Hamilton 

Nervous  diseases • 


H18 
1881 


MAY  ?4  -set 


1 


